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Proceedings of the U.S.-Mexico 

Border Conference 

on 

Women's Health 




Salud Sin Fronteras 



Health Without 
Boundaries 

September 26-28 ,1 995 



Proceedings of the U.S.-Mexico 
Border Conference 

on 
Women's Health 



September 26-28 ,1 995 



Organized by: 

The University of Texas System 

Texas-Mexico Border Health Coordinating Office (TMBHCO) 

Grant No. R13 CA/**65470-01 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



ACKNOWLEDGMENTS 

The University of Texas System, Texas-Mexico Border Health Coordinating Office (TMBHCO) 
appreciates the contributions of the following individuals in the planning of the US-Mexico Border 
Conference on Women's Health. 

Steering Committee: 

Beatriz A. Diaz-Apodaca, M.D., M.P.H., Conference Co-Chair 

Irasema Coronado, M.A. 

Graciela G. Garcia, M.S. CCC-SLP 

Edna Garza-Escobedo, Ph.D., R.N. 

Martha Gaytan 

Silvia B. Hartman, M.S.C. 

Susan Kunz, M.P.H. 

Teresa Kypuros, M.T. 

Sue G. Mottinger, Ph.D. 

Ana Maria Navarro, Ph.D. 

Marilyn North Arnold 

Leticia Paez, M.A., M.P.A. 

Amelie G. Ramirez, Dr.P.H. 

Faustina Ramirez-Knoll, L.M.S.W. 

Celia Ramos, Lie. 

Nora Ramos 

Rebeca L. Ramos, M.A., M.P.H. 

M. Sandra Sanchez, R.N., C.N.M. 

Sylvia J. Sapien, B.S.W. 

Cruz Torres, R.N., Ph.D. 

TMBHCO Staff: 

Paul Villas, Ed.D., CHES, Executive Director 

Doreen D. Garza, M.P.H., Assistant Director and Conference Co-Chair 

Marina Escobar 

Armando Lopez 

Sylvia A. Leal 

Lisa Lynne Montes 

Maira Lorena Guerra 

Nancy Gonzalez 

Thelma Vivian Garza 

NCI Staff: 

Elva Ruiz, Project Director 



Correspondence to: The University of Texas System, Texas-Mexico Border Health Coordinating 
Office, The University of Texas-Pan American, 1201 V\/est University Drive, Edinburg, Texas 78539- 
2999, Telephone: (956) 381 -3687, Fax: (956) 381 -3688 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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TABLE OF CONTENTS 

Page 

CANCER 

Breast and Cervical Cancer in Arizona 1 

Rosemary Lopez, M.B.A., and Bobbie O'Neil 
Cancer in Women Along the Texas-Mexico Border 5 

Nancy S. Weiss, Ph.D., and Susan E. Carozza, M.S.P.H. 
The Luces De Salud Program: Can Older Mexican- American Women Improve Their 
Mammography and Pap Smear Screening Behavior? 11 

Lucina Suarez, M.S.; Diane Simpson, Ph.D., M.D.; Donna Nichols, M.S.Ed.; and 

Rich Ann Roche, M.S. 
Cancer Prevention the "5-A-Day Way": The Role of Fruits and Vegetables in the Risk 
Control of Female-Related Cancers 13 

Maria Guzman, R.D., L.D. 
Lowering Barriers to Cancer Screening Among Hispanic Females in California 17 

Gil C. Sisneros, M.P.H., and David F. Goldsmith, Ph.D. 
Knowledge, Behavior, and Fears Concerning Breast and Cervical Cancer Among 
Older Low-Income Mexican-American Women 21 

Rich Ann Roche, M.S.; Lucina Suarez, M.S.; Diane Simpson, Ph.D., M.D.; and 

Dona Nichols, M.S.Ed. 
Addressing Barriers to Pap Smears Through Education 25 

Stephanie Hamilton, Ed.D., CT(ASCP); P. Ridgway Gilmer, M.D.; and Kristina Stroehlein, M.D. 
Results of a Pilot Survey of Knowledge, Attitudes, and Practices of Farmworkers 
About Cancer in General and Cervical Cancer in Particular 29 

Joanne M. Weinman, Carol A. Hooks, Gloria Fernandez, Julia E. Foxwell, Maricell Dean, 

James A. Dlhosh, Mary Ann Harrison, Ruth C. Brown, and L. Barbara Connally 

SMOKING 

Cigarette Smoking Among Latinas in California 35 

Ana M. Navarro, Ph.D. 
Tobacco Use Prevention in the Latino Community: The Por La Vida "Luchando" 
Project 41 

Lori McNicholas, M.A., R.D.; Karen Senn, Ed.D.; Ana M. Navarro, Ph.D.; and Bea Roppe 

REPRODUCTIVE HEALTH 

Sexually Transmitted Diseases in Adolescents 47 

Licenciado Gabino Hernandez Villarreal 
A Pregnancy Prevention Plan for High-Risk Youth 53 

Sheila Fitzpatrick, A.C.S.W. 
Adolescent Pregnancy: An Analysis of Family Context and Sexual Development . . 59 

Rosario Roman Perez, Esthela Carrasco Corona, and Elba Abril Valdez 
Maternal Behavior Under Two Forms of Feeding: Breast and Bottle 63 

Rosario Roman Perez, Cecilia Leyva Hernandez, and Maria Jose Cubillas Rodriguez 
Modern Contraceptive Technologies and Attributes: Preferences of Women Along 
THE U.S.-Mexico Border Region 67 

Sandra Guzman Garcia, M.Sc; Rachel C. Snow; and Ian W. Aitken 
Beliefs of the Pregnant Woman Assoclvted With Prenatal Care 75 

Ana Laura Quintero Crispin, M.D., and Dr. Charlotte Rappsilber 

Table of Contents Page v 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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HIV-AIDS 

Sex and Death: Issues Affecting Cultural and Sexual Behavior of Latin a Women in 

THE Era of aids 101 

Gloria Gallegos, M.S.N., M.P.H. 
"Ponte Trucha": A Campaign to Prevent AIDS 109 

Melba Muniz Martelon, Carlos Del Rio, Nora Gallegos, Jeremias Guzman, and Rodolfo Figueroa 
Hispanic HIV/AIDS Church Outreach 113 

Sister Mona Smiley, Ph.D. 
HTV/AIDS IN Women: Issues and Considerations for Minorities and Border 
Communities 117 

Selina Catala, M.S., LCDC 

OCCUPATIONAL HEALTH 

Analysis of Environmental Factors Determining a High Risk in Female Agricultural 

Day Workers 121 

Roberto de la Fuente Ruiz 
Taking Responsibility for Occupational Health: The Possibility of Involving 
Maquiladoras in Community Health Programs 125 

Alexandra Bambas, M.P.H. 
Pesticide Patch Testing: Californlv Nursery Workers and Controls 135 

Michael O'Malley, Pedro Rodriguez-H., and Howard I. Maibach 
Occupational Health and Safety Training for Maquiladora Workers Along the 
U.S.-Mexico Border 139 

Garrett Brown, M.P.H.; Leonor Norona Dioime, M.S.; Michele Gonzalez-Arroyo, M.P.H.; and 

Emily Merideth, M.P.H. 
The Reproductive Health Among Women Workers in the Maquiladora Industries in 
Tijuana, Baja California 143 

Cristina von Glascoe, Ph.D., M.D.; Gabriela Vazquez, M.A.; Miguel Angel Gonzalez Block, Dr. 

Sci.; and Sylvia Guendelman, Ph.D. 

COMMUNICATIONS 

Innovative Strategies in Delivering Health Care: The Promotora Model 155 

Maria Gomez-Murphy, M.A. 
The Health Library: A Model for Community Health Information Access 159 

Jennifer Cain Bohmstedt, M.P.A. 
Internet and Geographic Information System Technology: Bridging the U.S.-Mexico 
Information Frontier 163 

Deborah A. Salazar, Ph.D. 
Creating Support Systems for Colonia Women Through a Lay Health Promotion 
Outreach Program 171 

Elida S. Hernandez; Josefa Rodriguez, L.V.N.; and June Grube Robinson, M.P.H., R.D. 
Health Education for Nonreaders: Translating Across Cultures 175 

Aracely Rosales 

DIABETES 

Diabetes Education for Latinos: Translating Across Cultures 181 

Aracely Rosales 



Page vi Table of Contents 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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New Mexico Primary Care Diabetes Management Programs: A Lay Health Advisor 
Model 187 

Judith S. Hurley, M.S., R.D., and Katherine G. Bent, M.S.N., R.N. 
The Prevalence of Physical Exercise and Diabetes in a Sample Population of 
Monterrey, Nuevo Le6n 191 

Ruby M. Vargas Arriaga, M.S.P. 

MENTAL HEALTH 

Transforming Community Health Care: Impact of Depression and Distress on Somatic 

Complaints of the Distrejssed Latina 201 

Deborah Guadalupe Duran, Ph.D. 
Mental Illness: The Next Generation 207 

Dawn I. Velligan, Ph.D.; Bonnie C. Hazleton, M.A.; and Stacey L. Giesecke, M.S. 

VIOLENCE 

Violence Against Women 215 

Yoliria Joch Gonzalez 
Legal Options for Victims of Domestic Violence 219 

Jeana Lungwitz, J.D. 
Violence and Border Women: An Empowerment Model of Prevention and 
Intervention 227 

Linda K. Woodruff, D.S.W., LMSW-ACP, and Susan E. Hutchinson, Ph.D., LMSW-ACP 
Detection of Violence Against Women Through Organ-Neurosis 233 

Consuelo Maury de Santiago 
Identification of the Incidence of Domestic Violence Among Women Using Health 
Services 245 

Maria Concepcion Guzman Salazar, Adriana Lara Valencia, Elsa Babra Ramirez, and 

Grupo Feminista Alaide Foppa 

SPECIAL ISSUES 

Barriers to Empowerment in Health Care Consumerism 251 

Yvette Murray, Ph.D. 
Primary Health Care Services for Webb County Colonus 255 

Gloria Pefia, R.N.; Rose A. Saidivar, M.S.N., R.N.; Lisa Sanford, M.P.H., R.N.; 

Rosemary Welsh, R.S.M., R.N., and Donna Morris, Dr.P.H., C.N.M. 
A Telecommunication Strategy to Build New Mexico's Rural Primary Care 
Network 261 

Jo Fairbanks, Ph.D., and Diane Viens, D.N.Sc, C.F.N.P. 

POSTERS 

Preschool Immunizations in Hispanic Texans: The Effect of Sociodemographics, 

Knowledge, and Attitudes of Hispanic Mothers 265 

Diane M. Simpson, Ph.D., M.D., and Lucina Suarez, M.S. 
Prevention of Cervical Cancer Among U.S. Latinas 271 

Maria Eugenia Femandez-Esquer, Ph.D.; Amelie G. Ramirez, Dr.P.H.; and Roberto Villarreal, M.D. 



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CANCER 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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BREAST AND CERVICAL 
CANCER IN ARIZONA 

Rosemary Lopez, M.B.A. 

Chief, Arizona Border l-fealth Office 

Bobbie O'Neil 

Chief, Women's Comprehensive Cancer 

Program 

Arizona Department of l-fealth Services 

Bureau for Prevention and Health 

Promotion 

ABSTRACT 

The Women's Comprehensive Cancer Program was 
estabHshed to develop a plan to reduce cancer 
occurrence among Arizona women. Existing data 
show that Hispanic women tend to be diagnosed at 
later stages of cancer than non-Hispanic women. 
Because the key to cancer survival is early 
detection, the Program's objectives are to 
implement a screening program, train and educate 
health workers, and increase public awareness. 

Purpose of Study 

In 1992, the Arizona Department of Health Services 
established the Women's Comprehensive Cancer 
Program to develop a plan to implement a screening 
program to reduce suffering and death caused by 
cancer, especially breast, cervical, and ovarian 
cancer, among Arizona women regardless of race, 
income, or social position. 

Methodology 

Existing data on breast and cervical cancer in 
Arizona were published as a monograph. The study 
examined the incidence, stage at diagnosis, 
mortality, and survival of women with breast and 
cervical cancer. It included an overview of the 
population size and characteristics. The Arizona 
Cancer Registry (ACR) served as a primary source 
of data for this study. 

Results 

Breast Cancer 

Nationally, the two leading sites for cancer deaths 
among women are the breast and the lung. The 
incidence of breast cancer increases as women age, 
with the majority of breast cancer cases occurring 
among women 65 to 69 years of age. 



The number of breast cancer survivors can be 
augmented by increasing the proportion of cancer 
diagnosed as "early-stage disease." This study 
identifies the early stage as "local," the middle stage 
as "regional," and the advanced stage as "distant." 
Between 1980 and 1990, the ACR found that 58% 
of all breast cancer cases were diagnosed in the 
local stage, 32% in the regional stage, and 6% in the 
distant stage. 

Hispanic women tend to be diagnosed in much later 
stages of the disease, with 9% in the distant stage 
and 37% in the regional stage. Among Arizona's 
Hispanic population, a fluctuating pattern over time 
is observed for the mortality rates from breast 
cancer. 

Cervical Cancer 

In contrast to breast cancer, invasive cervical cancer 
is commonly diagnosed in women who are 
relatively young. Projections for invasive cervical 
cancer among women 1 8 years of age and older 
show an increase in the number of cases through the 
year 2030. 

As with breast cancer, the key to reducing the 
mortality rate fi^om invasive cervical cancer is 
detection of early-stage disease. Between 1980 and 
1990, 50% of Arizona's invasive cervical cancers 
were diagnosed in the local stage, 33% in the 
regional stage, and 1 1% in the distant stage. Fewer 
Hispanic women than non-Hispanic women are 
diagnosed in the local stage, while more Hispanic 
women have their cancers discovered in the regional 
stage. 

Conclusions 

The key to increasing survival and reducing 
mortality fi-om breast and cervical cancer is early 
diagnosis. This requires regular screening. The less 
favorable socioeconomic conditions of many 
minority women often prevent them from obtaining 
medical care. Therefore, the Arizona Women's 
Comprehensive Cancer Program's objectives are to 
provide improved mammograms and Pap smears, 
training and education for health care providers, and 
increased awareness of breast and cervical cancer to 
benefit all at-risk Arizona women. 

Women's Comprehensive Cancer Program 

■*■ Arizona Department of Health Services 



Cancer 



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Program Mission: 

■*- To improve the quality of life for Arizona women, 
especially the uninsvired, by implementing a 
statewide comprehensive women's health program 
that offers early cancer detection services. 

Program Goals-. 

-*- To increase participation in cancer screening by 
developing and implementing systems to promote 
comprehensive, high-quality breast and cervical 
screening activities. 

American Cancer Society Statistics: 

-*■ The chances of a woman getting breast cancer have 

more than doubled since 1940. 
■*- One out of eight women will develop breast cancer 

in her lifetime. 
^ Approximately 46,000 women will die of breast 

cancer this year in the United States. 
-*■ The 5-year survival rate for women with early 

detection of breast cancer is 92%. 

Reproductive Factors Increasing Risk for 
Breast Cancer: 

■*- Early age at menarche 

^ Late onset of menopause 

■*■ First birth after age 35 

-*- Nulliparity 

Other Factors Possibly Increasing Risk of 
Breast Cancer: 

■*■ Genetic - inherited risk 

■*■ Dietary factors 

■*■ Gender 

■*- Obesity 

-^ Age 

Breast Cancer Warning Signs: 

■*- Discharge from the nipple 
-*- Thickening in the breast tissue 
■*■ A lump in the breast 

-*- The skin of the breast appears dimpled— like the 
surface of an orange 

Breast Cancer Facts: 

■*■ Breast cancer can occur without warning signs. 
-*■ More than 80% of all breast lumps are not 

cancerous. 
-*- If detected and treated early, the 5-year survival 

rate is greater than 90%. 

Screening — Breast Cancer Self-Exam (BSE): 

■*■ Most breast cancers are found through breast self- 
examination. 

■*■ BSE should be done once a month, after 
menstruating. 



■*- After menopause, BSE should be done on the same 
date each month. 

Screening — Clinical Breast Exam (CBE): 

-*■ A health care provider looks for change in the 
shape or size of the breast and feels the breast, 
chest, and armpit for any thickening or lumps. 

^ CBE should be done once each year. 

Screening — Mammography: 

■*- An X-ray of the breast that can find breast tumors 
when they are too small to be detected by a woman 
or her health care provider during breast 
examination. 

-*■ ACS Guidelines: 

^ The first mammogram should be done by age 40. 

-^ Between ages 40-49, a mammogram should be 
done every 1-2 years. 

->■ After age 50, a mammogram should be done every 
year. 

Cervical Cancer Facts: 

■*■ 500,000 cases diagnosed worldwide each year 
■*■ 13,500 cases diagnosed annually in the United 

States (1993) 
■*- 4,400 women died from cervical cancer in the 
United States (1993) 

Suspected Cause for Cervical Cancer: 

■*■ Research conducted since 1980 in 22 countries 
has convinced most physicians that Human 
Papilloma Virus (HPV), a common sexually 
transmitted virus, is the most common cause of 
cervical cancer. 

Risk Factors for Cervical Cancer: 

■*- Sexual behavior - multiple partners 

->■ Early onset of sexual intercourse 

-*■ Cigarette smoking 

■*- Immune system suppression 

Cervical Cancer Warning Signs: 

->■ Most often, no visible sjonptoms appear. 

• Vaginal discharge 

• Irregular or unusual vaginal bleeding 

Screening Pap Smear: 

-*■ This is an inexpensive exam that helps health care 
providers identify abnormal cells before they 
become cancerous. This exam has contributed 
significantly to cervical cancer's high 5-year 
survival rate (66%). 

->- When a woman becomes sexually active or at age 
18, an annual exam is recommended. 



I 

1 



Page 2 



Cancer 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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Barriers to Screening: 

-*■ Modesty 

■*■ Unaware that the woman is at risk 

■*■ Fear that the procedure may be painful 

■*■ Physician does not recommend an exam 

-»- Uninformed about the need for screening 

■*■ Linguistic and/or cultural barriers 

■*■ Transportation 

^ Cost 

Outreach and Screening-. 

■*- Community health advisers conduct community- 
level activities and interventions that promote 
health and prevent disease. These advisers are 
trusted, respected members of the community and 
serve as bridges to the health care system. 

Common Terms for Community Health 
advisers: 

-*■ Community Health Volunteer 

-»► Lay Volunteer 

-^ Health Liaison 

■*■ Paraprofessional 

-»- Home Visitor 

■*■ Peer Counselor 

■*■ Indigenous Health Aide 

■*■ Public Health Outreach Worker 

-»- Lay Community Health Worker 

->► Promotora 

■*- Lay Health Worker 

-»- Resource Mother 

A SURVEY OF ARIZONA'S PRON\OJORA 
PROGRAMS 

Survey A/I ETHODS 

-»- Identified the sample of programs (N=44) 

-*- Distributed survey questioimaires 

-*- Response from 17 programs (15 usable) 

-»- Second follow-up mailing 

■*■ Final sample (N=22) 

FINDINGS: POPULATION SERVED BY PROGRAMS 

■*■ Anglo 9 

■*■ Native-American 13 

-*■ Latino(a) 22 

^ African- American 10 

^ Asian-American 4 

■*- Males . 6 

-»- Females 18 

■*■ Families 16 



Prenatal care 
Family planning 



54.5% 
63.6% 



Method of Identifying Promotoras 

■*■ Interview community leaders 72.7% 

-*- Community social event 18.2% 

■*■ Focus groups 9.1% 

* Other methods 31.9% 
Multiple responses acceptable 



Focus of Programs 

■*■ Breast cancer 
-»- Cervical cancer 



40.9% 
40.9% 



Criteria Used to Select Promotoras 




-*- 


Age 


40.9% 


->- 


Personality 


86.4% 


->- 


Assertiveness 


54.5% 


->- 


Racial Group 


22.7% 


^- 


Ethnic Group 


72.7% 


^ 


Socioeconomic Status 


22.9% 


^ 


Gender 


54.5% 


^ 


Language 


77.3% 


Ma 


Other 

JOR Components of Training 


54.5% 


■* 


Project goals 


72.7% 


-*■ 


Birth control methods 


54.5% 


-*■ 


Anatomy 


50.0% 


-*- 


Time management 


54.5% 


-*■ 


Biology of cancer 


22.7% 


->■ 


Recordkeeping 


72.7% 


->■ 


Diagnosis/treatment 


27.0% 


-*- 


Role playing 


59.2% 


-*■ 


Communications 


68.2% 


-*■ 


Teaching methods 


50.0% 


■*- 


Role oi promotora 


72.7% 


Responsibilities of Promotora 




^ 


Teach on-site classes 


54.5% 


^ 


Teach classes in centers 


59.1% 


■* 


Teach classes in homes 


63.6% 


-*- 


Educate individuals 


68.2% 


Payment AND Incentives 




-*■ 


Volunteer 


22.7% 


* 


Graduation ceremony 


59.1% 


-*■ 


$4.00 - $5.00 


18.2% 


■^ 


Cosmetics/perfume 


9.0% 


-*- 


$6.00 - $7.00 


18.2% 


-^ 


Gift certificates 


13.6% 


■* 


$8.00 - $9.00 


31.8% 


-*- 


Parties 


22.7% 


■*■ 


$10.00+ 


4.5% 


->- 


AU day retreat 


13.6% 


-»- 


Aimual amount 


4.5% 


->- 


Awards 


18.2% 


ILa salud de las mujeres es importante! 


■* 


Women's health is important. 





Cancer 



Page 3 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



CANCER IN WOMEN ALONG 
THE TEXAS-MEXICO BORDER 



Nancy S. Weiss, Ph.D. 
Susan E. Carozza, M.S.P.H. 

Texas Cancer Registry 

Texas Department of l-lealth 

Austin, Texas 78756-3199 



ABSTRACT 

The purpose of the study was to describe the 
distribution of cancer incidence and mori:ahty 
among Texas women residing in 14 Texas counties 
bordering Mexico. Cancer incidence data were 
collected by the Texas Cancer Registry of the Texas 
Department of Health (TDH) for 1990-92, and 
cancer mortality data were collected by the TDH 
Bureau of Vital Statistics for 1990-93. Data were 
analyzed to determine race/ethnic and age-specific 
differences. Total numbers and age-adjusted and 
age-specific rates are presented for major cancer 
sites. Preliminary results indicate that Hispanic 
women in the Texas border counties experience 
lower incidence and mortality rates than Anglo 
women for many cancer sites, including colorectal, 
lung, melanoma, breast, ovarian, and corpus uteri; 
however, Hispanic women experience higher rates 
of stomach, liver, gallbladder, kidney, and cervical 
cancers than Anglo women in this area of Texas. 
Patterns of age-specific rates for individual cancer 
sites also vary across ethnic groups. In summary, 
cancer incidence and mortality in Texan women 
living along the U.S. -Mexico border vary by cancer 
site among the different race/ethnic and age groups. 
The variability observed may be partly due to 
differences in risk factors influenced by 
socioeconomic status and cultural practices, such as 
diet, occupation, access to care, and use of health 
resources. 




Population Distribution by Race/Ethnicity 
Anglo (63°/ 

African- 
American (12%) 




Hispanic (25%) 

Texas, 1990 

Anglo (19%) 

African- 
merican 
(2%) 




Hispanic (79%) 

Border Counties, 1990 



Cancer 



Page 5 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



I 



Cancer Incidence, 1 990- 1 992 

Race/Ethnic Differences in Leading Sites 













Rank 




Cases" 


k 


%of 
Total 


Breast 

Anglo 
Hispanic 


266 

352 


31 
28 


1 
. 1 


Lung 

Anglo 
Hispanic 


117 
92 


14 
7 


2 
3 


Cervix 

Anglo 
Hispanic 


18 
108 


2 
9 


7 
2 


Colon 

Anglo 
Hispanic 


81 
69 


10 
6 


3 
4 



Cancer Mortality, 1 990- 1 993 

Race/Ethnic Differences in Leading Sites 



Average annual number of cases 







%of 


Rank 




Deaths* 


Total 


Lung 

Anglo 
Hispanic 


87 
64 


24 
12 


1 

2 


Breast 

Anglo 
Hispanic 


64 
95 


17 
18 


2 
1 


Colon 

Anglo 
Hispanic 


35 
28 


10 

5 


3 

7 


Pancreas 

Anglo 
Hispanic 


19 

35 


5 
6 


6 

3 




Average annual number of deaths 



Leading Cancer Sites, Incidence* 

Females. Texas-Mexico Border Counties 



Leading Cancer Sites, Mortality* 

Females. Texas-Mexico Border Counties 




B Anglo 

■ Hispanic 



Breast Lung Cervix Colon Corpus Ovary 
Uteri 



* Age-adjusted average annual incidence rates based on 1990-92 data 



S o 

o 



Anglo 
Hispanic 




TO 


0) 


o 

TO 


X 

> 


6 


o 

c 


h 

o 


O 




Q. 


Ui 





a> o 
m O 



*Age-adjusted average annual mortality rates based on 1990-93 data 



Pages 



Cancer 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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Breast Cancer Incidence and Mortaujy* 

Females. Texas-Mexico Border Counties 

■Anglo Incidence 
Mortal! 




20 25 30 35 40 45 50 55 60 65 70 75+ 

Age 

* Age-adjusted average annual rates; incidence rates based on 1990-92 data; mortality rates 
based on 1990-93 data 

Lung Cancer Incidence and Mortality* 

Females. Texas-Mexico Border Counties 



O 
O 

o 

o 

o 



350 1 
300 
250H 
200 
150- 
100- 
50 




-o- Anglo Incidence 
-X- Anglo Mortality 
-A- Hispanic Incidence 
~- Hispanic Mortality 




T 1 1 1 r 

20 25 30 35 40 45 50 55 60 65 70 75+ 

Age 

* Age-adjusted average annual rates; incidence rates based on 1990-92 data; 
mortality rates based on 1990-93 data 



Cancer 



Page 7 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



Colon Cancer Incidence and Mortality* 

Females. Texas-Mexico Border Counties 



Cervical Cancer 

Race/ethnic differences in diagnosis 
and mortality 



1 



•I 



300-. 
250- 
200- 
150- 
100- 
50- 




o- Anglo Incidence 
• Anglo Mortality 
-•- Hispanic Incidence 
- Hispanic Mortality 



.——'' 




20 25 30 35 40 45 50 55 60 65 70 75+ 



•Age-adjusted average annual rates; incidence rates based on 1990-92 data; mortality 
rates based on 1990-93 data 




InsHu 



Invasive 



Mortality 



♦Average annual rates; in situ and invasive lates based on 1990-92 c 
mortality lates based on 1990-93 data 



Cervical Cancer Incidence and Mortality* 

Females. Texas-Mexico Border Counties 



o 
o 
o 

o" 

o 

4-1 

m 
0^ 



60 -| 
50 - 
40 - 



Anglo Incidence 
Anglo Mortality 
-Hispanic Incidence 
Hispanic Mortality 




20 25 30 35 40 45 50 55 60 65 70 75+ 

Age 

*Age-adjusted average annual rates for invasive cancers only; incidence rates based 
on 1990-92 data; mortality rates based on 1990-93 data 



Pages 



Cancer 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



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Cervical Cancer 

Percent Diagnosed at In Situ Stage, by Race/ 
Ethnicity 



Breast Cancer 

Texas Border vs. California Rates* 



0) 

< 




40 60 

Percent in situ 



@CA Anglo 
1 Border Anglo 
D CA Hispanic 
■ Border Hispanic 




Incidence Mortality 

♦California incidence and mortality rates based on 1988-92 data; 
Texas border incidence rates based on 1990-92 data; mortality rates 
based on 1990-93 data 



Breast Cancer 

Race/ethnic differences in diagnosis 
and mortality* 

120n 



S 




Breast Cancer 

Texas Border vs. Texas Rates* 



iTX Anglo 
i Border Anglo 
D TX Hispanic 
■ Border Hispanic 




Insiti 



invasive 



Mortality 



8 15 



Mortality 
"Texas and border mortality rates based on 1990-93 data 



*Average annual rates; in situ and invasive rates based on 
1990-92 data; nwrtality rates based on 1990-93 data 

Breast Cancer 

Percent Diagnosed at In Situ Stage, by Race/ 
Ethnicity 



0) 
O) 

< 




10 15 

Percent in situ 



Lung Cancer 

Texas Border vs. California Rates* 



B CA Anglo 
1 Border Anglo 
D CA Hispanic 
Border Hispanic 




Incidence Mortality 

*Califomia incidence and mortality rates based on 1988-92 data; 
Texas border incidence rates based on 1990-92 data; mortality rates 
based on 1990-93 data 



Cancer 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



Lung Cancer 

Texas Border vs. Texas Rates* 



Cervical Cancer 

Texas Border vs. Texas Rates* 



I Border Aiglo 
QlXHsperic 
■ BsderHspsric 




Molality 
Teas axl bcrcler nrotality rates based en 199098 data 



Cervical Cancer 

Texas Border vs. California Rates* 



g 14 
<» 12 



■ CA Anglo 
B Border Anglo 
a CA Hispanic 

■ Border Hispanic 




Incidence 



Mortality 



♦California incidence and mortality rates based on 1988-92 data; 
Texas border incidence rates based on 1 990-92 data; mortality rates 
based on 1990-93 data 



■ TXAi^ 
BBonJerA)^ 
itXHspalc 
I BunJui'Hspaic 




6 
5 
4 
I 3 

1 



MsUSlfy 

"ToasatJ Latter ntrtdiVdESbEBBcl en 19GOS8cHa 



Potential Impact of Increased Cervical Cancer 
Screening Along the Border 

Assuming Pap screening is 100% effective in 
preventing invasive disease and death 

> Number of preventable invasive cases per year: 

• Border Anglos - 1 8 

• Border Hispanics - 108 

> Number of preventable deaths per year: 

• Border Anglos - 7 

• Border Hispanics - 33 

Average years of potential life lost annually: 752 



1 



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1 



THE LUCES DESALUD 

PROGRAM: CAN OLDER 

MEXICAN-AMERICAN WOMEN 

IMPROVE THEIR 

MAMMOGRAPHY AND PAP 

SMEAR SCREENING 

BEHAVIOR? 

Lucina Suarez, M.S. 

Diane Simpson, Ph.D., M.D. 

Donna Nichols, M.S.Ed. 

Rich Ann Roche, M.S. 

Texas Department of Health 

Austin, Texas 

ABSTRACT 

We tested a community program involving peer 
role models, media, volunteers, and a services 
consortium to determine if it improved the use of 
mammography and Pap smear screening among 
older Mexican-American women. The inter- 
vention, Luces de Salud (Health Lights), was 
implemented in El Paso in 1991. Baseline surveys 
assessed cancer screening behaviors, knowledge 
and attitudes, and demographic and acculturation 
characteristics. Postintervention surveys were 
conducted in 1995. Impact measures indicate that 
the Luces de Salud program improved some aspects 
of cancer screening. The size of the intervention 
effect is being assessed from the pre- and 
postsurveys. Peer role models in combination with 
accessible screening services can change the 
behavior of low-income Mexican-American 
women. 

Background 

With funding from the National Cancer Institute, 
the Texas Department of Health conducted a 5 -year 
community-based project to improve screening 
rates for older Mexican- American women. Previous 
studies showed that Mexican-American women 
have the lowest participation rates in cancer 
screening for any race/ethnic group. 



Study Design 

The intervention program Luces de Salud was 
implemented in El Paso in 1991. Mexican- 
American neighborhoods in Houston served as the 
comparison community. Baseline surveys assessed 
cancer screening behaviors, knowledge and 
attitudes, and demographic and acculturation 
characteristics. Cancer screening participation was 
low in both communities: only 21% of El Paso 
women and 24% of Houston women had a recent 
mammogram. The percent of older women with a 
recent Pap smear was 46% in El Paso and 50% in 
Houston. The 3 -year intervention involved the use 
of peer role models in the media, peer volunteers, 
and a services consortium that provided free 
screenings to eligible women. Postintervention 
surveys were conducted in 1995. 

Intervention Activities 

The intervention was based on Bandura's social 
learning theory of social modeling and social 
support. To role-model the screening behavior and 
provide social reinforcement, Mexican-American 
women were recruited from the target community. 
Role models appeared in the media with positive 
stories about cancer screening. Peer volunteers 
reinforced the messages by handing out newsletters 
to their friends and neighbors. During the 3 years of 
intervention, 62,121 newsletters were distributed in 
neighborhoods, clinics, and churches by 543 peer 
volunteers. A total of 143 role-model stories 
appeared in the local media in El Paso during the 
first 2 years of intervention. In the third year, 429 
radio and 300 television public service 
announcements featuring role-model stories were 
broadcasted. 

Impact of Intervention 

>- 1,792 telephone inquiries to the outreach office 
>^ 3,966 Pap smears and 3,538 screening 
mammograms 

Effect of Intervention 



Change in Screening Rates, 1991-95 



Pap smear 
Mommogrophy 



El Paso 

+ 6.2% 
+ 17.1% 



Houston 

+ 2.9% 
+ 16.1% 



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Change in Pap Smear Screening Rates 
by Age, 1991 to 1995 


12.6% 13-6% 


9.0% 


1.6%; 






-4.^% 


-9.2% 


■^° 46I49 66-64 65+ 
El Paso 


40-49 50-64 65+ 
Houston 



Change in Mammography Screening Rates 
on byAge, 1991 to 1995 


1fiw20-3% 


20.7''/^.2,2% 


^^^ 13.0% 1 i 






4.5% i 
1 { i 








on - 


■^ 40-49 50-64 65+ 
BPaso 


40-49 50-64 65+ 
Houston 



Change in Pap Smear Screening Rates 

by Language of Interview 

1991 to 1995 



English 
Spanish 



El Paso 
-11.4% 
+8.8% 



Houston 
-40.0% 
+ 5.4% 



Change in Mammography Screening 

Rates by Language of Interview 

1991 to 1995 



English 
Spanish 



El Paso 

-3.3% 

+ 20.9% 



Houston 
+ 16.0% 
+ 16.6% 




Summary of Results 

>■ Small intervention effect on Pap smear screening 
>* No intervention effect on mammography 
>• Pap smear intervention effect in women 50+ 
>* No mammography intervention effect in women 

50+ 
>* Pap smear intervention effect in Spanish speakers 
>» Some mammography increase in El Paso Spanish 

speakers 



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CANCER PREVENTION THE 

"5-A-DAYWAY": THE ROLE OF 

FRUITS AND VEGETABLES IN 

THE RISK CONTROL OF 

FEMALE-RELATED CANCER 

Maria Guzman, R.D., L.D. 
Texas Department of Health 

ABSTRACT 

The purpose of this program is to inform health care 
workers, providers, and agencies about the national 
5-A-Day fruit and vegetable campaign's role in 
chronic disease prevention, thereby increasing 
awareness of an underutilized cancer-related 
community intervention. The program consists of 
a review of the dietary factors associated with 
cancer risk, the specific nutrient basis supporting the 
fruit and vegetable campaign for better health, and 
a discussion of the current community interventions 
being conducted to increase awareness and practice 
of eating five servings of fruits and vegetables every 
day through the 5-A-Day coalitions. Barriers 
include language, general lack of knowledge 
regarding the dietary impact on the development of 
cancer and other chronic diseases, cancer paranoia 
and the current epidemic of cancers of unknown 
etiology, and lack of knowledge regarding the 
convenient and appetizing preparation of fruits and 
vegetables. Program highlights include explanation 
of the most current findings and recommendations 
regarding dietary practices thought to be associated 
with cancer development, antioxidant vitamins, 
fiber, and other micronutrients. Explanations of 
how to use 5-A-Day brochures, 5-A-Day recipes, 
and a review of the past year's activities of the local 
Rio Grande Valley 5-A-Day coalitions are also 
included. 

Cancer Prevention The 5-a-day Way-. The Role 
OF Fruits And Vegetables in The Risk Control of 
Female-related Cancers 
Objectives 

>- Increase awareness of national 5-A-day 

> Review dietary factors associated with cancer risk. 



>" Match specific micronutrients to different types of 

female-related cancers 
>^ Inform on role of fruits and vegetables in chronic 

disease prevention 
>* Discuss current community interventions aimed at 

increasing awareness and promoting behavior 

change 

Conclusions 

>■ Mortality is up by 7% in relation to other diseases 

>* Incidence is up by 1 8% 

>- Response to intervention is rapid in breast, 

prostate, children's, testes, cervix, and non- 

Hodgkin's Lymphoma 
> Mortality reduced most in the young 
>" Population differences remain unexplained 
>* Survival has increased only 4% overall 
>- Since 1950, mortality is up 10% 

Annual Cancer Deaths in United States 1 950-90 




Lung Cancer 



All Other Cancers 



Source: Beardsley, T, (1994) Scientific American 270:130-138 



Cancer Mortality Percent Change by Age 1 973 
- 1990 



Mortality 



0-19 




20-44 


^^^^H 


45-54 


^m 


55-64 


■ 


65-74 


^^^ 


75+ 


■■■■ 


<65 


■ 


65+ 


■^^H 


11 ages 


■i 



-30 -20 -10 10 20 

Percent Change 

Age Adjusted to 1970 Standard Population 



Cancer 



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i 



Cancer Among U.S. Ethnic/Racial Groups -All 
Sites Combined 




Incidence 1977-83 



Atortality 1 977-83 



50 100 150 200 250 300 350 400 
Incidence and mortality per 100,000, all rates age adjusted in 1970 

Nutrition And Cancer Progress 

25% to 35% of cancers may be related to dietary 
factors 

>" NCI's current dietary guidelines: 

• reduce fat to 30% or less of calories 

• increase fiber intake to 20 to 30 g/day 

• increase fruits and vegetables to at least 5 
servings a day 

^ Healthy people 2000 nutrition components: 

• reduce fat to 30% or less of calories 

• increase complex carbohydrates and fiber- 
containing foods of adult diets 

• "reduce overweight to a prevalence of no more 
than 20% of people aged 20..." 

Dietary Factors And Cancer Risk 

>■ Fat intake 

>^ Energy iatake 

>- Alcohol 

>* Red meat 

>* Refined sugars 

Nutrients AND Cancer Risk 

>■ Vitamin A 

^^ Beta-carotene 

:s^ Vitamin C 

>^ Folate (& Methionine) 

>* Vitamin E 

>- Dietary fiber 

>- Allium vegetables 

Recommended Dietary Allowances (RDA), 
Dietary Sources, and Usual Intakes 

>- Vitamin A: 

• RDA for Vitamin A for women is 800 RE 



• Preformed Vitamin A or Retinoids are found 
mainly in liver, liver oil, fortified miUc, and 
eggs 

• Carotenoid precursors, which include Beta and 
Alpha Carotene and Cryptoxanthin, are found 
in carrots, dark green leafy vegetables, and 
vegetable-based soups. Carotenoids that lack 
any Provitamin A activity can be found in any 
yellow or orange vegetable. 

• Average daily intake for women is 1,170 RE 

> Vitamin C: 

• RDA for Vitamin C for women is 60 mg 

• Vitamin C is found in a variety of fruits and 
vegetables including green and red peppers, 
coUard greens, broccoli, spinach, tomatoes, 
kiwi, potatoes, strawberries, oranges, and other 
citrus fruits. 

• Average daily intake for women is 77 mg 
^^ Folic Acid: 

• RDA for folic acid for women is 1 80 
micrograms 

• Foods high in folate are dark green leafy 
vegetables, legumes, and some fruits (citrus 
and papaya). As much as 50% can be 
destroyed during preparation, processing, and 
storage. 

• Average daily intake for women is 149 
micrograms 

5^ Vitamin E 

• RDA for Vitamin E for women is 8 mg 

• The richest sources in the U.S. diet are the 
common vegetable oils and the products made 
from them. Wheat germ, nuts, and green leafy 
vegetables supply appreciable amounts. 

• Average daily intake for women is 7.1 mg 

Fiber 

>■ 25 to 35 g of fiber are recommended daily. Usual 
intakes for the American public range from 10 to 
15 g per day. 

>^ Dietary fiber decreases intestinal transit time, and 
due to its hygroscopic nature, dilutes carcinogens 
in fecal matters, thus reducing exposure of the 
colonic mucosa to these carcinogens. 

> A diet high in fiber including fruits, vegetables, 
and whole grain bread and cereal products would 
be most protective against cancers of the distal 
colon and rectum. 

Dietary Factors And Breast Cancer Risk 

>■ Statement: Major source of the dietary fat 

hypothesis is the observation that per capita fat 



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1 



consumption around the world is highly correlated 
with national breast cancer mortality rates. 

FAT AND BREAST CANCER RISK 
>- Problems 

• Type of fat needs to be differentiated 

• Fat versus dietary pattern 

• Influence of fat in adolescence 

• Very low intake of fat 

Other Cancers Affecting Women 

5* 



Lung 

Colon 

Skin Cancer (Melanoma) 

Ovarian 

Cervix 



Changes in U.S. Cancer Death Rates 
1973- 1990 



Lung (females) 






Skin melanomas 


W"^ 




Liver 


ef 


Over Age 65 


Lung (males) 


0^^ 




All Sites 
Breast (females) 


D^ 


Under Age 65 


Brain 






Leukemia 


c-^ 




Mouth and pharynx 


m 




Thyroid 


tS 




Stomach 


^m 




Uterine cervix 


^^ 





Dietary Factors and Lung Cancer Risk 

>■ RetinolA'^itamin A 
>* Carotenoids 
5^ Vitamin C 

Challenges Facing Diet and Cancer Progress 

>■ Further research on dietary factors and individual 

susceptibility 
5> Develop recommendations for high-risk groups 
^ Educate consumers 
5> Estimate impact of dietary change on cancer risk 

Rio Grande Valley 5-a-day Coalition 

>■ Established in July of 1994 to promote the health 
message of the national 5-A-day campaign from 
NCI and PBH: 

• To consume 5 or more servings of fruits and 
vegetables every day for better health.. 

• Increase awareness of the importance of eating 
5 or more servings of fruits and vegetables 
every day. 

• Provide consumers with specific information 
about how to incorporate more servings of 
fruits and vegetables daily. 



50 100 150 

Percent Change 
Source: Beardsley, T. (1994) 
Scientific American 270:130-138. 




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Rio Grande Valley 5-a-day Activities 

>- Media: talk shows, interviews, press releases, 
food demonstrations, contests, presentations, 
PSA's, etc. 

> Schools: coloring contests, lesson plans, 
presentations, basket deliveries, cafeteria displays, 
etc. 

>- Health fairs and conventions: booths, 

presentations, literature dissemination, etc. 

> WIC: promotion through all agencies with 
inclusion into coalition events and literature 
dissemination. 

>* Translate 5-A-day materials into Spanish 

Rio Grande Valley 5-a-day Activities 



5> 



Increase Spanish material availability 

Establish a speakers' bureau at local 

C.O.C.'s for 5-A-day presentations 

Winter fruit and vegetable promotion 

Basket deliveries to local media personalities 

Texas 5-A-day week and salad head competition 

Continued food demos on television and at retail 

and industry sites 

Newsletter 

Access Region 1 TV Channel 1 

Involve city government, proclamations... 

Canned food drives 

Culinary education project 



5-A-DAY Brochures 

>■ Provide basic health and nutrition information on 

the purpose of 5-A-day 
>^ Offer useful tips on the advantage of eating more 

salads and making salads healthier 
>* Make fruit and vegetables the holiday/party 

choice for both preparation and giving 
>" Show how fruits and vegetables are a convenient 

and healthier alternative to empty-calorie snacks. 
>- Show how fruits and vegetables can rehydrate and 

replenish before, during, and after physical 

activity. 



Rio Grande Valley 5-a-day Contact(s) 

Maria Guzman, R.D., L.D. 
Chronic Disease Nutritionist 
Texas Department of Health 
Public Health Region 1 1 
601 West Sesame Drive 
Harlingen, Texas 78550 
(210)423-0130 

Doreen D. Garza, M.P.H. 

Health Education Coordinator 

Texas-Mexico Border Health Coordinating Office 

University of Texas - Pan American 

1201 West University Drive 

Edinburg, Texas 78539-2999 

(210) 381-3687 



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I 



LOWERING BARRIERS TO 

CANCER SCREENING AMONG 

HISPANIC FEMALES IN 

CALIFORNIA^ 



Gil C. Sisneros, M.P.H.^ 

David F. Goldsmith, Ph.D.^ 

Agricultural Cancer Prevention Project 

Western Consortium for Public Health, 

Merced, California 

ABSTRACT 

The purpose of this study is to evaluate the 
effectiveness of a cancer prevention education 
program on knowledge and behavior among 
Hispanic farmworkers in Merced County, 
California. Lay health educators conducted a 
bilingual (Spanish-English) health education 
program during 1994 and 1995 for cervical and 
breast cancer prevention among 1,150 healthy 
farmworkers. Their knowledge was tested before 
and after educational encounters and significance 
was measured by t-tests. Subjects who participated 
in the education programs were given vouchers to 
attend local clinics for free cancer screening exams. 
Knowledge was gained on all items tested. In 
addition, 15.5% and 5% of the attendees redeemed 
vouchers for cervical cancer and breast cancer 
checkups, respectively. The education programs 
produced statistically significant improvements in 
knowledge about cancer risks and preventive 
behaviors and resulted in higher screening rates for 
both cervical and breast cancer. 



Supported by CDC-NIOSH Cooperative 

Agreement #U03/CCU9 10 107-02. 

2 
Current address: Department of Health Services, 

Cancer Detection Section, MS #294. P.O. Box 942732, 

Sacramento, CA 94234-7320. 

Current address: Public Health Institute, 2001 
Addison Street. 2"'' floor; Berkeley, CA 94704-1103. 



Background AND Purpose 

The Agricultural Cancer Prevention Project, based 
in Merced, California, is a 3 -year project funded by 
a grant from the Centers for Disease Control and 
Prevention. The objectives of the project in the first 
year were to gather baseline data on farmworkers' 
knowledge, attitudes, and practices about breast and 
cervical cancer and to determine the barriers for 
cancer screenings. 

In years two and three, the project implemented and 
tested the effectiveness of a culturally sensitive, 
bilingual education program and outreach strategies 
to achieve increased knowledge about breast and 
cervical cancer among female farmworkers and 
their families. This paper examines preliminary 
findings of knowledge gained and evidence of 
behavioral change as measured by the proportion of 
women receiving screening for cervical and breast 
cancer. 

Methods 

Using the information gathered in year one, lay 
health educators conducted a bilingual health 
education program during 1994 and 1995 for 
cervical and breast cancer prevention among 1,105 
healthy farmworkers. The health education was 
conducted primarily in Spanish in a culturally 
sensitive manner and addressed misconceptions 
about cancer that exist in the farmworking 
communities in Central California. The project did 
not use traditional methods, that is, brochures, radio, 
and TV, but incorporated sfrategies that rely upon 
natural women leaders in the Hispanic community 
who could engage and build upon the trust of the 
primary social network (family or comadres 
(Godmothers), fictive kin) of the culture. Health 
education strategies included group presentations, 
"Pap parties," and individual encounters (see Vega, 
Sisneros, and Goldsmith, 1995; and Gomez, 
Sisneros, and Goldsmith, 1995, for detailed 
descriptions of the "Pap party"). 

All participants in the program completed a pretest 
and post-test questionnaire to test knowledge about 
cancer. Second post-tests were administered to 
approximately 10% of the participants 45 days after 
their initial contact. Average gains in knowledge 
were measured using t-tests. Subjects who 



Cancer 



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i 



participated in the education programs were given 
vouchers to attend local Golden Valley Health 
Center (GVHC) clinics for cancer screenings. Staff 
outreach was designed to overcome barriers for 
migrant and seasonal farmworkers. Some of the 
services offered by staff included patient regis- 
tration at GVHC (a federally funded migrant clinic), 
appointment scheduling, certification for income- 
eligible cancer screening programs, follow-up of 
abnormal screens, translation services, and 
transportation. 

Results 

The project conducted five focus groups and eight 
health fairs at migrant camps in the first year. 
Information was gathered on the knowledge, 
attitudes, and practices of Hispanic (mostly 
Mexican-American) farmworkers concerning 
cancer. In addition, barriers for cancer screenings 
were identified. A majority of the participants in 
the focus groups acknowledged a strong fear and 
fatalistic attitude concerning cancer. Fatalismo 
(there is virtually nothing a person can do to prevent 
or survive cancer) and other misconceptions about 
cancer were expressed by many of the participants. 
Barriers for cancer screening identified during the 
focus groups and health fairs included limited 
income and transportation, inflexible work 
schedules, lack of knowledge about health care 
services and cancer screenings, language barriers, 
lack of female providers, and other cultural issues. 

In year two, the project implemented an evaluation 
component that included a questionnaire, a pretest, 
and a post-test. Preliminary data from the pretests 
and post-tests indicate knowledge gains on all items 
tested, with statistically significant (p<0.05) 
improvements on questions related to smoking, 



prevention of cancer, treatability of cancer (rather 
than dying from it), and prevention of death. For 
example, more than 90% of the participants 
answered correctly on post-tests questions 
concerning the prevention of cancer, the association 
between smoking and cancer, the risk factors for 
cervical cancer, and the importance of a Pap smear, 
compared with only 30% on pretests. Similarly, 
more than 70% of the participants answered 
correctly questions on post-tests concerning breast 
cancer and the importance of breast screenings, 
compared with only 18% on pretests. In regard to 
behavioral changes, 24% and 17% of the eligible 
participants redeemed vouchers at local clinics for 
cervical cancer and breast cancer checkups, 
respectively. A more recent summary of findings 
was published that included a total of 1,732 
participants. The results were similar to those in 
this paper (Goldsmith and Sisneros, 1996). 

CONCIUSIOHS 

Preliminary results indicate that education and 
outreach strategies produced statistically significant 
improvements in knowledge about cancer risks and 
preventive behaviors. Our program resulted in 
higher screening rates for both cervical and breast 
cancer also compared to other means of outreach to 
Spanish-speaking farmworker women. The 
preliminary findings can be attributed to several 
innovative educational and outreach strategies, 
including a lay health education program conducted 
by bilingual community outreach staff and 
Promotoras, directed to migrant and seasonal 
farmworking women (Meister, Warrick, Zapein, and 
Wood, 1992). 



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Goldsmith DF, Sisneros GS, Cancer Prevention 
Strategies among California Farmworkers: Preliminary 
Findings. Journal of Rural Health 1996: 12(343-348). 

Gomez H, Sisneros GS, Goldsmith DF. Successful 
linkage of outreach and cancer screening: A case study 
of 1 1 Hispanic women . U.S. -Mexico 1995 Border 
Conference on the Health Status of Women, September 
26-28, 1995, South Padre Island, Texas. 



Meister JS, Warrick LH, Zapein JG, Wood AH. 
Using lay health workers: Case study of a 
community-based prenatal intervention. Journal of 
Community Health . 1992;17(1). 

Vega M, Sisneros GS, Goldsmith DF. The "Pap party": 
An improved method for cervical cancer prevention 
among Hispanic women . U.S. -Mexico 1995 Border 
Conference on the Health Status of Women, September 
26-28, 1995, South Padre Island, Texas. 



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KNOWLEDGE, BEHAVIOR, 
AND FEARS CONCERNING 
BREAST AND CERVICAL 
CANCER AMONG OLDER 
LOW-INCOME MEXICAN- 
AMERICAN WOMEN 

Rich Ann Roche, M.S. 

Lucina Suarez, M.S. 

Diane Simpson, Ph.D., M.D. 

Donna Nichols, M.S.Ed. 

Texas Department of Health, Austin 

ABSTRACT 

We examined how knowledge and attitudes related 
to cancer affected mammography and Pap smear 
screening behaviors among older Mexican- 
American women. The data are from baseline 
surveys conducted before the start of community 
interventions to improve cancer screening rates. 
Scales were developed that assessed a woman's 
knowledge of signs and symptoms, screening 
guidelines, detection methods for breast and cervical 
cancer, and fear of cancer. Results of the study 
reinforce the importance of motivating and 
educating Mexican- American women about cancer 
screening. Given appropriate information, low- 
income Spanish-speaking women follow screening 
guidelines. 

Background 

The Texas Department of Health received a 5 -year 
National Cancer Institute grant in 1990 (#R01- 
CA52977) to improve screening rates for older 
Mexican- American women through a community- 
based intervention. El Paso was selected as the 
intervention site because a prior study identified the 
west Texas city and county as having excessively 
high mortality rates of breast and cervical cancer 
compared to the State overall. Also, cancer 
screening rates were low: in 1991 only 21% of 
El Paso women had a recent mammogram and 46% 
had a recent Pap smear. During the first year, 
preintervention cross-sectional baseline surveys 



were conducted in El Paso and Houston to assess 
cancer screening behaviors, related knowledge and 
attitudes, as well as demographic and acculturation 
characteristics. A community-based program, Luces 
de Salud (Health Lights), was implemented over the 
following 3 years and was completed in December 
1994. Postintervention surveys were recently 
conducted in both communities. Evaluation of the 
program and analysis of the survey data will be 
completed over the next year. 

Introduction 

Although recent studies have documented the low 
level of participation of Hispanic women in cancer 
screening, few have examined the predisposing 
knowledge and attitudes concerning cancer of older 
Hispanic women. In this study, we document the 
knowledge and fears concerning cancer of an older 
population of Mexican-American women and how 
these factors are related to screening behavior and 
other sociodemographic characteristics. 

Study Variables 

We measured knowledge of cancer prevention 
behavior, detection methods, screening guidelines, and 
attitudes toward cancer. Knowledge of cancer 
prevention behavior was assessed from responses to 
the question "What can a person do to prevent 
cancer?" Women who volunteered an answer such as 
"Do not smoke" or "Good nutrition" were coded as 
knowing a cancer prevention behavior. Women who 
answered "I don't know" or "A person cannot do 
anything" were grouped together. Knowledge of 
breast and cervical cancer detection methods was 
measured from responses to an open-ended question 
on what kind of checkups find cancer early. Women 
were given one point for each of the following 
methods mentioned: pelvic exam. Pap smear, breast 
self-exam, clinical breast exam, and mammogram. 
To assess knowledge of screening guidelines, 
respondents were asked how often a woman their age 
should have a Pap smear and a mammogram. Correct 
responses were that a woman should have a Pap smear 
at least once a year and have a mammogram every 2 
to 3 years if age 40 to 49 or yearly if age 50 or older. 
We created an attitudinal scale toward cancer by 
counting the number of the following statements with 
which they agreed: "Cancer freatment is worse than 
the disease;" "Just about anything can cause cancer;" 



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I 



"If I had cancer, I would not want to know;" "A 
person's chances of surviving cancer are poor;" and 
"I worry a lot about getting breast cancer." Scores 



ranged from zero to five with five indicating the most 
fatalistic, anxious, and fearful attitude toward cancer. 



Level of Knowledge by Age 



Do not know cancer 
prevention 



Do not know cervical cancer 
detection methods 



Do not know breast cancer 
detection methods 




20 40 60 

Percentages 



n40- 


49 


^50- 


•64 


■ 65 + 



80 



Level of Knowledge and Fear by Age 



Do not know pap smear 
screening guidelines 



Donotltnow mammography 
screening guidelines 



Most fear ofcancer 




□ 40-49 

■ 50-64 

■ 65 + 



20 40 60 80 100 

Percentages 



Level of Knowledge by Ability to Speak English 



Do not know cancer prevention 
behaviors 



Do not know cervical cancer 
detection methods 



Do not know breast cancer 
detection methods 



^ 






1 






1 1^^^^ 



20 40 

Percentages 



^eak English Well 

Do not ^eak English Well 



60 



Page 22 



Cancer 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



Level of Knowledge and Fear by Ability to Speak English 



Mos 1 Fear of 
Cancer 

Do N ot K n ow 

Mam m ography 

S creen In g 

Guidelines 

Do notl^now 
Pap Smear 
Screening 
G u Id elin es 

C 




- 














H 




[-]Do NotSpeak English 
■ Speak English Well 


Well 
















B 








B 


■ 


20 


40 60 
Pe rce ntages 


80 


100 







Results 



Prevalence of a Recent Pap Smear Screening 



Cancer 




Screening 




Prevention 


** 


Guidelines 


** 


Behaviors 








Know 1 or more 


51.1% 


Know 


53.4% 


behaviors 




Don't know 


36.2% 


Don't know or can't 


26.2% 






do anything 
















Cervical Cancer 




17otii> nf 












Methods 


** 




* 






Know 2 exams 


63.7% 


Least Fear 


53.5% 


Did not mention 


36.2% 


Most Fear 


43.8% 


either exam 









Prevalence of a Recent Mammography Screening 



Cancer 




Screening 








Guidelines 


** 






Behaviors 




Know 1 or more 

behaviors 
Don't know or can't 

do anything 


23.3% 
20.0% 


Know 
Don't know 


40.4% 
15.8% 










Cervical Cancer 
detection IVfetliods 


** 


Fear of 


Cancer 








Know 2 exams 
Did not mention 
either exam 


45.7% 
18.4% 


Least Fear 
Most Fear 


25.1% 
23.6% 



Discussion 

Mexican- American women who don't speak English 
well are: 

5> Least knowledgeable about screening guidelines 

and detection methods 
>► The most fearfiil of cancer 

Mexican- American women age 65 and older are: 

5^ Least knowledgeable about screening guidelines 

and detection methods 
>" At greatest risk for breast and invasive cervical 

cancer 

Recommendations 

>■ Breast and cervical cancer interventions should 
focus on older Mexican- American women. 

> Interventions should incorporate educational 
messages in Spanish that are appropriate for 
Mexican Americans. 



*P<0.05 for trend in proportions between categories 
**P<0.001 for trend in proportions or differences between categories 



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i 



ADDRESSING BARRIERS TO 

PAP SMEARS THROUGH 

EDUCATION 

Stephanie Hamilton, Ed.D., CT(ASCP) 

P. Ridgway Gilmer, M.D. 

Kristina Stroehlein, M.D. 

Health Science Center 

School of Medicine 

The University of Texas at Houston 

ABSTRACT 

Nationwide, Pap smear screening has significantly 
reduced the incidence of invasive cervical cancer. 
In the Rio Grande Valley, however, women are still 
experiencing a high mortality rate from this disease. 
In this paper we provide information to health care 
practitioners and community leaders about 
socioeconomic factors and, particularly, educational 
issues that may deter women from obtaining a Pap 
smear. 

One barrier may be the lack of knowledge about the 
test and the importance of routine screening. Over 
the past several years, confroversy has arisen 
regarding cervical screening. Some women are 
unsure about the frequency of obtaining a Pap 
smear, the accuracy of the test results, and the 
meaning and implications of the reported diagnosis. 
This conftision may fiirther discourage women from 
having a Pap smear performed. We seek to clarify 
these issues and to positively influence women to 
seek screening and ultimately reduce their risk of 
cervical cancer. 

Introduction 

It is undisputed that the Pap smear has contributed 
significantly to the decline of invasive cervical 
cancer among women in the United States. Over the 
past 30 years, the incidence and mortality rates have 
declined 3-4% each year. In 1960, there were 
20,000 cases of invasive cervical cancer compared 
with 13,000 cases in 1991. During this same period. 



the death rate decreased from 41 per 10,000 to 5 per 
10,000 (Dewar, Hall, and Perchalski, 1992). 
However, cervical carcinoma is still the sixth most 
common cancer among women (American Cancer 
Society, 1991). Moreover, current data show a 
significant increase in precancerous cervical lesions 
in women under age 50 (American Cancer Society, 
1995; Dewar, et al., 1992). One report indicated a 
600% increase in the diagnosis of cervical 
infraepithelial neoplasia between 1970 and 1988 
(Dewar, et al., 1992). Although this change may be 
due in part to improved screening detection and 
diagnosis, there is evidence that a substantial 
increase in the occurrence of carcinoma-m-^/^M 
(CIS), which is the stage immediately preceding 
invasive cervical carcinoma, will be diagnosed in 
65,000 women this year. Estimates for 1995 are 
that 15,800 women will develop invasive carcinoma 
of the cervix and that 4,800 women will die from 
the disease (American Cancer Society, 1995). Thus, 
cervical cancer remains a significant disease, 
particularly among economically disadvantaged 
women. Precancerous lesions and invasive cervical 
carcinoma are particularly high in women of lower 
socioeconomic status (Dewar, et al., 1992; Miller, 
Roussi, Altman, Helm, and Steinberg, 1994). 
Moreover, there is an increase of cervical cancer 
among Black and Hispanic women. 

The highest rate worldwide of invasive cervical 
carcinoma is in South America, where the rates are 
six to seven times greater than in the United States 
and where "one case-control study found a ninefold 
increase in the relative risk of invasive cervical 
cancer when women did not receive screening for 
cervical cancer" (Dewar, et al., 1992). 

The lower Rio Grande Valley area has the highest 
rate of deaths due to cervical cancer in the United 
States (Oleszkowicz, Kresch, and Painter, 1994). 
Although mortality rates during the 1980s decreased 
for Anglo and Black women (35% and 18%, 
respectively), Hispanic women accounted for only 
a 0.5%) decline (Oleszkowicz, et al., 1994). 

Purpose 

Socioeconomic barriers exist that preclude women, 
particularly Hispanic women, from obtaining 
cervical cancer screenings (i.e.. Pap smears). In 



Cancer 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 




addition, a lack of understanding about the 
importance of routine Pap smears, the controversy 
over their effectiveness, and the confusion or fear 
related to the diagnosis are potential problems. 
These facets may also adversely affect physicians in 
performing cervical examinations. Health care 
providers and community leaders must be 
knowledgeable about the Pap smear test to assist 
women to be educated, motivated, and treated 
appropriately to decrease mortality from cervical 
cancer. 

Barriers to Cervical Screening 
Empirical data indicate that economic factors, 
including lack of health insurance coverage, are 
strong predictors of failure to obtain preventive 
care. "As a result, screening tests are, in effect, 
'reverse targeted' to populations least in need, since 
those at higher risk for disease are also most likely 
to be uninsured and hence unscreened" 
(Woolhandler and Himmelstein, 1988). However, 
even those with insurance are discouraged by 
required copayments, deductibles, and failure of 
many policies to cover screening. A recent study 
showed that more than 85% of women, including 
those with insurance, had not received a Pap smear 
within the past 4 years. A higher percentage of 
Hispanic (3.4%) and African- American women 
(4.1%) were unable to receive health care, compared 
with 2.5% of whites and others (Himmelstein and 
Woolhandler, 1995). Another study conducted in 
the Rio Grande Valley revealed income as the most 
significant predictor to women not receiving a Pap 
smear. The study also identified lack of knowledge 
about the need for a Pap test and its importance as a 
major barrier (Oleszkowicz, et al., 1994). Women at 
high risk for cervical cancer must be aware of the 
importance of routine screening. Mortality rates are 
excessively high for Hispanic women primarily due 
to lack of early detection (Oleszkowicz, et al., 
1994). The incidence of invasive cervical cancer is 
reduced by 64.1% for screening performed every 10 
years versus a decrease of 90.8% for screening 
performed every 3 years (Dewar, et al., 1992). 
However, the appropriate frequency remains 
confroversial. Before 1980, the American Cancer 
Society recommended that all women receive a Pap 
smear annually. The Society amended its position 



in 1980 to two negative Pap smear results and then 
at least every 3 years until 65 years of age. The 
American College of Obstetricians and 
Gynecologists has always recommended annual Pap 
smears for most women. Now the American Cancer 
Society is adopting this policy again but states that 
after three consecutive annual negative results, the 
frequency can be decreased at the physician's 
discretion (Makerc, Fried, and Kleinman, 1989). 
One reason for advocating an annual Pap smear is 
the recent increase in reports of misdiagnoses. 
"False negatives," in which Pap smears are reported 
as normal but contain abnormal precancerous or 
cancerous cells, are of major concern. Tragic cases 
of women dying of cervical carcinoma because their 
Pap smears were reported incorrectly as negative 
have been highlighted via television and newspaper 
media over the past several years. False-negative 
rates range from to 80%, with a probable estimate 
of 20-40% (Dewar, et al., 1992). Another report 
estimates a false-negative rate of about 25% 
(Rassaiah, 1992). A false-negative Pap result can be 
due to sampling error, in which the abnormal cells 
were not included in the specimen; screening error, 
in which the cytologist failed to recognize abnormal 
cells; or interpretive error, in which the cytologist 
failed to accurately identify abnormal cells. A 
recent study indicated that screening and 
interpretive errors account for one-third of the false- 
negative results, whereas most errors were due to 
inadequate sampling (Dewar, et al., 1992). 
Inadequate smears that lack endocervical cells 
should be repeated (Gearhart, Davey-Sullivan, and 
Fulton, 1991). In contrast to the high false-negative 
rates, the false-positive rates are between 0.2 and 
1.3%. This indicates that an abnormal diagnosis is 
more reliable than a negative or normal test result. 
One common error is for clinicians to rely on a 
"negative" test result subsequent to an abnormal 
cytology result when there has been no histological 
excision. Although it is possible for low-grade 
neoplasms to regress spontaneously or for 
inflammatory atypias to resolve after treatment, 
follow-up smears after an abnormal result should be 
examined carefully (Dewar, et al., 1992). 

In addition to fear regarding the Pap smear's 
accuracy, women may be concerned about the 



Page 26 



Cancer 



[ 



U.S. - MEXICO 199? BORDER COSFEREyCE OS WOMES'S HE.AlTTl 



1 



meaning of an abnormal diagnosis. This ma>" 
further deter them from obtaining follow-up (Miller. 
et al., 1994). Many laboratories still use the original 
"Class" s\-stem even though a scheme called the 
Bethesda System was designed for uniform 
reporting of results. These reporting s^'stems are 
summanzed b€lo\\' (Dewar, et al., 1992; Gearhart, et 
al., 1991). 

Schemes for Reporting Pap Smears 



Ctiw 


Worid Health 
OrganiratiGQ 


Cervical 
IntraepiUielial 

Neoplasia 

[.CIS) 


The 
Bethesda 

S.TFtein 


! 


V:rT- 


S:r^ 


v^-:-J^ zc-za: 


n 


._. -_ 




^^---^ 




in 


Maters 


as: 

CSl 


Sc=— >-cs 
graleSIL 

STL 


i\' 


5;^^^-- 


ass 


ffiaii grade Sn. 


V 


scr 


^Ilzi±f' 


^^omctK .-yJI 



One concern is that a woman recei\-ing a Class 11 
result which generalh' denotes mflammator\' at\pia. 
may logically assume that she has cemcal cancer 
because the result was not a Class I. Thus, fear may 
cause significant delays in treatment, contradicting 
the very reason for ha\ing a Pap smear. 

Health care pro\iders, armed with correct 
information, can be instrumental in clarifying 
misconceptions surrounding the Pap smear. Further 
educational efforts are needed to encourage women 
at high nsk for cenical cancer to recognize the 
importance of the Pap smear, strengthen their 
confidence m the test and understand the 
implications of its results so that they -will seek 
appropriate treatment. 



Cancer 



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1 



REFERENCES 



American Cancer Society. Cancer facts and figures 
1995 . New York: American Cancer Society, 1995. 



American Cancer Society. 
CA, 1991:41(19-36). 



Cancer statistics, 1991. 



Dewar MA, Hall K, Perchalski J. Cervical cancer 
screening: Past success and future challenge. Primary 
Care . 1992;19(3). 

Gearhart JG, Davey-SuUivan BJ, Fulton LJ. 
Management of the abnormal Pap smear. Journal of 
Mississippi State Medical Association . 

1991;32:5(159-64). 

Himmelstein DU, WooUiandler S. Care denied U.S. 
residents who are unable to obtain needed medical 
services. American Journal of Public Health . 
1995;85(3). 



Makerc DM, Fried VM, Kleinman JC. National trends 
in the use of preventive health care by women. 
American Journal of Public Health . 1989;79 
(21-6)Miller SM, Roussi P, Altman D, Hehn W, 
Steinberg A. Effects of coping style on psychological 
reactions of low-income, minority women to 
colposcopy. Journal of Reproductive Medicine . 
1994;39:9(711-8). 

Oleszkowicz KL, Kresch GM, Painter JT. Pap smear 
screening in family physicians' offices in a rural area 
with a high cervical cancer rate. Family Medicine . 
1994;26:10(648-650). 

Rassaiah B. Comments. Canadian Medical 
Association Journal . 1992;146:8(1279-1280). 

Woolhandler S, Himmelstein DU. Reverse targeting of 
preventive care due to lack of health insurance. Joumal 
of the American Medical Association . 
1988;259: 19(2872-2874). 



I 



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1 



RESULTS OF A PILOT SURVEY 

OF KNOWLEDGE, ATTITUDES, 

AND PRACTICES OF 

FARMWORKERS ABOUT 

CANCER IN GENERAL AND 

CERVICAL CANCER IN 

PARTICULAR 

Joanne M. Weinman 

Carol A. Hooks, PATH^ 

Gloria Fernandez, Julia E. Foxwell, 

Maricell Dean, James A. DIhosh, 

Mary Ann Harrison, 

Ruth C. Brown, Telamon^ 

L. Barbara Connally, NIOSH 

ABSTRACT 

A pilot survey of knowledge, attitudes, and practices 
of migrant and seasonal farmworkers regarding 
cancer in general and cervical and skin cancer in 
particular was conducted in four mid- Atlantic States 
— Delaware, Maryland, Virginia, and West 
Virginia. The surveys were collected through a 
convenience sample design using one-to-one 
interviews. There were 578 completed surveys in 
both English and Spanish. Most of the Spanish 
speakers had immigrated from Mexico and several 
Central American countries to do farmwork in the 
United States. 

Three general questions on cervical cancer were 
asked of both men and women respondents and 
were followed by more specific questions asked of 
only the women respondents. The results of the 
general questions, as well as the more specific ones, 
suggest that knowledge and understanding about 
cervical cancer and Pap smears are fairly low 
among the farmworkers surveyed. A follow-up 



' PATH is a nonprofit, nongovernmental international 
organization dedicated to improving health, especially the 
health of women and children. 

^ Telamon Corporation is a private, nonprofit agency whose 
purpose is to serve those in need. 



Study to this pilot and an educational intervention are 
planned. 

Background 

The Program for Appropriate Technology in Health 
(PATH),' Telamon Corporation,^ and the National 
Institute for Occupational Safety and Health 
(NIOSH) are working together to help reduce illness 
and death associated with skin and cervical cancer in 
farmworker populations in the States of Delaware, 
Maryland, North Carolina, Virginia, and West 
Virginia. The project is funded by the Centers for 
Disease Control and Prevention (CDC) under a 
CDC/NIOSH cancer control initiative aimed at 
helping to meet the health promotion and disease 
prevention objectives of the U.S. Public Health 
Service's "Healthy People 2000" plan. 

This 3 -year demonstration project is organized into 
three phases. During phase 1, a baseline assessment 
was conducted and collaborative relationships were 
established with community health organizations. 
Phase 2, the intervention phase, consists of 
administering pre- and post-intervention question- 
naires, observing and recording pre- and post- 
intervention behaviors, and implementing a health 
navigator outreach model. In phase 3, the results of 
the project will be documented and disseminated. 

Setting 

Beginning in the spring and ending in the fall of each 
year, an estimated 15,000 migrant agricultural 
workers (and sometimes their family members) 
travel to the mid- Atlantic United States to work in 
plant nurseries, vegetable farms, and fruit orchards. 

The situation analysis conducted during phase 1 
demonstrated that working with farmworkers 
presents great variability and many unknowns. It 
became clear that the project's success would be 
affected by the migratory nature of a significant 
proportion of the target population; the lack of 
knowledge regarding feasible and appropriate 
mechanisms for access to farmworker communities 
within the context of this project; the need to 
determine the validity and practicality of draft 
research instruments and processes; and the need to 
assess the local situation, political climate, and 
prospects for formulation of collaborative efforts 
with regard to cancer prevention and control 



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\ 



I 



Sampling Methods and Survey Design 

During phase 1 and following the situation analysis, 
a pilot study was conducted to collect baseline data 
on farmworkers' knowledge, attitudes, and practices 
(KAP) that would be used to design an appropriate 
educational intervention on skin and cervical cancer. 
Adult migrant and seasonal farmworkers employed 
in Delaware, the eastern shores of Maryland and 
Virginia, and West Virginia were sampled for the 
quantitative portion of the study. (Telamon/North 
Carolina collected only qualitative data during this 
phase.) Eighty percent of the farmworkers in these 
four states were employed in the study area, and all 
types of agricultural labor with which these states' 
farmworkers were involved were present in the 
study area. 

It was decided that the farmworkers would be 
sampled according to where they lived, so the labor 
camps or other housing on or near growers' property 
served as the unit of intervention. During the 
baseline data collection, staff sampled the 
population according to the unit of analysis (i.e., 
housing locations), taking into consideration a 
combination of the following criteria: 

>* An appropriate and representative variety of group 
housing where large numbers of farmworkers in the 
specific catchment area lived and where systematic 
random sampling would be feasible 

>" Smaller housing units such as trailers, small 
individual houses, and farmhouses where families, 
including women (every effort was made to survey 
as many women as possible), lived and where it was 
possible to obtain a sample of everyone in the 
housing unit 

> Locations where access was granted to Telamon 
staff by growers and crew leaders 

>- Likelihood that farmworkers living in these places 
would return the following year 

>^ Other criteria such as language and/or ethnicity 

Results 

A total of 578 people completed the KAP 
questionnaire through face-to-face, verbal 
interviews. Some of the people who were given the 
questionnaire lived in randomly selected 
housing units and others lived in units selected 
by convenience. 



Sample Characteristics of All Respondents 

Nineteen percent were seasonal farmworkers and 
81% were migrants. Sixty-seven percent were men 
and 33% were women. Latinos comprised 55% of all 
respondents; the remaining 45% consisted of African 
Americans, Haitians, and white Americans. Fifty- 
five percent of respondents reported that they prefer 
to speak Spanish; 41% reported that they prefer 
English; 2% reported that they prefer Haitian Creole; 
and 2% reported that they use Spanish and English 
equally. 

Characteristics of Latino Migrants Only 

Of the Latino migrants sampled, 72% were men and 
28% were women. The average age of respondents 
was 33. Sixty-five percent were bom in Mexico, 
1 8% were bom in other Latin or Central American 
countries, and 17% were bom in the United States or 
Puerto Rico. Fifty-six percent of the men and 37% of 
the women were neither married nor living with a 
partner. Forty-six percent had no children. Of those 
who had children, 62% had between one and three 
children, 20% had four to six children, and 15% had 
more than six children. Sixty-four percent reported 
that their 1993 household income was less than 
$10,000, with a mean of approximately four people 
dependent on that income. The mean number of 
completed school years was four, with 60% reporting 
a lOth-grade education or less. 

Knowledge Regarding Cervical Cancer 

When asked, "What do you think a Pap smear is?" 
85% of men and 44% of women were unable to 
answer correctly. Responses considered acceptable 
ranged from "a test for female problems" to "a test 
for cervical cancer." 

When asked if they had ever heard of cervical cancer, 
74%) of men and 65%) of women surveyed said they 
had not. Women were then asked several other 
questions regarding their experience with pelvic 
exams and Pap smears. Among women who had not 
had a Pap smear in the past 3 years, most said the 
reason was that they did not know they needed one. 
Those same women were asked if anyone had ever 
advised them to get a Pap smear, and the majority 
answered "no." 

All of the women surveyed were asked how 
concemed they were about getting cervical cancer. 
Forty-one percent said they were very concemed, 



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1 



12% were somewhat concerned, and 35% were not 
at all concerned. 

Discussion 

The findings from this survey further document that 
migrant and seasonal farmworkers have low 
incomes and low educational levels. Because the 
majority of the farmworkers in this study were 
Spanish speakers, it was evident that they 
confronted barriers related to language and culture 
as well. These conditions predict that members of 
this group would face knowledge, access, and 
financial barriers to prevent or detect early any 



illness, including cancer. 

Specifically, the study confirmed that the majority of 
Latino respondents had a low level of knowledge 
about prevention, early detection, and diagnosis of 
cancer in general and cervical cancer in particular. 
Additionally, it showed that the majority of Latina 
women who responded had not received health 
messages encouraging them to get Pap smears, and 
these results suggest that educational campaigns 
might prove effective in reaching this population. 



Cancer 



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]| 



SMOKING 



U.S. -MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



CIGARETTE SMOKING AMONG 
LATINAS IN CALIFORNIA' 

Ana M. Navarro, Ph.D. 
University of California, San Diego 

ABSTRACT 

This paper presents estimates of cigarette smoking 
prevalence for Latinas in California based on the 
random digit dial 1 990 California Tobacco Survey. 
Indicators of smoking dependence among current 
cigarette smokers and exposure to second-hand 
smoke among non-smokers are also presented. The 
results indicate lower smoking prevalence among 
Latinas of low level of acculturation and high level 
of education. These results are compared with 
available data on prevalence of cigarette smoking 
along the U.S. -Mexico border. 

Methods 

Details of the survey design for the CTS can be 
found in the technical report prepared by Pierce and 
colleagues (1992). The survey was conducted by 
telephone in either Spanish or English between June 
1990 and February 1 99 1 . Three questionnaires were 
used to implement the CTS: the Screener Survey, 
the Adult Attitudes and Practices Survey, and the 
Youth Attitudes and Practices Survey (Table 1). 
The Screener Survey is answered by one of the 
members of the household who is at least 18 years 
old and includes questions concerning demographic 
information and the current smoking status of every 
member of a selected household. The Adult 
Attitudes and Practices Survey collects detailed self- 
report data for adults aged 18 or over on tobacco use 
and related topics as well as socio-demographic 
information. We refer to the Adult Attitudes and 
Practices Survey as the "extended" survey. Table 2 
presents the total number of non-Latino white and 
Latino respondents for each of the survey 
instruments. 



'Funded by The Tobacco Tax Health Protection Act of 
1988, Proposition 99, TRDRP grant no. 3KT-0031 



Results 

Figure 1 shows estimates of smoking prevalence 
and pertinent 95% confidence intervals based on the 
Screener Survey. Smoking prevalence among adult 
Latinas was estimated at 12.5%. 

Figure 2 includes estimates of smoking prevalence 
among Latinas and non-Latino white women. The 
results are broken down by level of acculturation 
and years of formal education. The results indicate 
that smoking prevalence is consistently lower 
among Latinas than among non-Latino white 
women at all levels of formal education. 

Figures 3, 4, and 5 present data on three indicators 
of nicotine dependence among smokers: 
(a) percentage of daily smokers (Figure 3); (b) 
percentage of smokers who smoke more than 14 
cigarettes per day (Figure 4); (c) percentage of 
daily smokers who smoke the first cigarette of the 
day within 30 minutes upon awakening (Figure 5). 
The results suggest that nicotine dependence 
estimates based on percentage of daily smokers 
(Figure 3) and average number of cigarettes per day 
(Figure 4) is lower among Latina smokers than 
among non-Latino white women. No statistically 
significant differences in nicotine dependence as 
estimated by latency to smoking are detected 
among daily smokers of different ethnic 
background (Figure 5). 

Figure 6 presents the distribution of female smokers 
by quitting stage. Quitting stage refers to the length 
of time a former smoker has been abstinent, as well 
as to the intention among current smokers to quit in 
the near future (Cohen, Lichtenstein, Prochaska, 
Rossi, Gritz, Carr, Orleans, Schoenbach, Biener, & 
Abrams, 1989, DiClemente, Prochaska, Fairhurst, 
Velicer, Velazques, & Rossi, 1991). The results 
suggest that approximately half of the Latina 
smokers have recently quit or are in the process of 
quitting smoking cigarettes. 

The results presented in Figure 7 suggest that a 
lower percentage of Latina smokers compared to 
non-Latino smoker women has ever been told by a 
doctor to quit smoking. These results could be due 
to the fact that a higher percentage of Latinas 



Smoking 



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1 



compared to non-Latinas do not have a regular 
health care provider. Also, the lower nicotine 
dependence among Latina smokers could explain 
this result. 

Figures 8 and 9 present data relevant to second-hand 
smoke exposure among non-smoker women. The 
results among Latina non-smokers of low level of 
acculturation indicate that (a) more than half (58%) 
of them work in places where there are no 
restrictions to smoking and (b) 42% are exposed to 
second-hand smoke in their working area (Figure 8). 
Figure 9 shows the percentage of non-smoker 
women who choose to sit in the non-smoking area 
when they go out to eat and the percentage of 
women who have ever asked someone not to smoke 
in a certain situation in the past year. 

Tables 3, 4, and 5 present data published by the Pan 
American Health Organization (1992) on smoking 



and exposure to environmental tobacco smoke 
among non-smokers in Mexico. 

Table 6 shows data from the only study identified 
that specifically reports smoking rates among 
women in the U.S.-Mexico border. 

Conclusions 

>- Estimates from the 1 990 California Tobacco Survey 

show that 12% of Latiaas in California smoke 

cigarettes. 
>" Smoking prevalence and nicotine dependence are 

lower among Latinas of low level of acculturation 

compared to Latinas of high level of acculturation 

and non-Latinas. 
>- Exposure to secondhand smoke is high among 

Latina non-smokers in California. 
>* Data on smoking among Latinas at the U.S.-Mexico 

border are iosufficient. 



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Smoking 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



Zi 



Table 1 . Survey Instruments for the 1 990 
California Tobacco Survey (Pierce, etal., 1992) 

>■ Screener Survey 

>► Adult Attitudes and Practices Survey 

>* Youth Attitudes and Practices Survey 

Table 2. Sample Size (57,244 Screened 
Households) 



Screener Survey 




• Non-Latino White 


70,997 


• Latinas 


28,000 


Extended Adult Interview 




• Non-Latino Whites 


18,021 


• Latinas 


3,509 


Extended Youth Interview 




• Non-Latino Whites 


2,972 


• Latinas 


3,261 



Figure 1. Smoking Prevalence Among Adult 
females: california tobacco screener survey 
1990 




■ Non-Latino 

@ Latino High Acculturatio 

■ Latino Low Acculturation 



Males Females 

Figure 2. Smoking Prevalence Among Adult 
females: california tobacco screener survey 
1990 




■ Non-Lallno 

M Latino High Acculturation 

■ Latino Low Acculturation 



<I2 15 >12 

Years of Formal Education 



Figures. Nicotine Dependence Among 
smokers: percentage of daily smokers 




■ Non-Latino 

B Latino High Acculturation 

■ Latino Low Acculturation 



Males Females 
California Tobacco Survey 1990 



Figure 4 . Nicotine Dependence Among Smokers: 
More Than 1 4 Cigarettes Per Day 




Non-Latino 

Latino High Acculturation 

Latino Low Acculturation 



Males Females 

California Tobacco Survey 1990 

Figure 5. Nicotine Dependence Among 
Smokers: Latency to Smoking Upon 
Awakening 




■ Non-Latino 

□ Latino High Acculturation 

■ Latino Low Acculturation 



Males Females 
California Tobacco Survey 1990 



Smoking 



Page 37 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



i 



^ 



Figures. Quitting Stage Among Female 
Smokers 




Ngtv Latino L^'no 



Latino 



Ace 



Low 
ficc 



E3 iVfairierBnQe 

■ Alion 

H Ciiituiplation 

■ RxxitorplsliGn 



G^ifiGniaTGbaoooSUvey1990 



Figure 8. Smoking Policy At Work Among 
Female Non-smokers 




Non- Latinos Latinos 
Latinos High Low 

Ace. Ace. 

California Tobacco 
Survey 1990 



QNo restrictions 



Lesser 
Restrictions 



Work Area Ban 



Total Ban 




42 



Jul 

NHL 

Smoking in Work Area 



Figure 7. Doctor Advised To Quit Smoking-. 
Female Smokers 




Non- 


Latino 


Latino 


Latino 


K^ 


Low 




Aoc. 


Ax. 



Figure 9. Avoidance of Environmental 
Tobacco Exposure Among Female Non- 





SMOKERS 












(U 

5 

c 

2 
Q. 


4 


^ 


_____ 


21.8 I 












QNever 

■ Rarely 

■ Half the Time 

■ All ttie time 




■ Na«r 

■ Not Last Visit 

■ LastN^sit 










990 




rm 


L 


68 

ill 



NHL 



California Tobacco Suvey 1990 

NorvLatinos Latinos hSgh Latinos Low 

Ace Ace Asked Not To Smoke 

California Tobacco Survey 1990 

Table 3. Surveys on Tobacco Use and Prevalence of Current Daily Smoking by Sex, Mexico 











Prevalence of Current Smoking 


Author/Sponsor 


Year 


Samnifi 


N 


Men 


Women 


Both 




























Joly (PAHO) 


1971 


Mexico City 
Age 15-74 


1,574 


43.6 


16.0 


28.7 


National Health Survey (ENSA), 
Secretaria de Salud 


1986 


National 
Age> 12 


14,528 


27.4 


8.4 


17.4 


National Survey on Addictions, (ENA), 
Secretaria de Salud 


1988 


Urban Residents 
Age 12-65 


12,581 


43.1 


20.0 


25.8 


Gallup (American Cancer 
Society) 


1988 


Mexico City 
Age> 18 


2,600 


37.0 


17.0 





Source: PAHO. 1992 



Page 38 



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I 



J ABIE 4. Prevalence of Current Daily Smoking by 
Sex AND Geographic Area Mexico, 1 988 



Region 


Prevalence of Current Daily 
Smoking (%) 
Men Women 


Northwest 


28.4 


16.6 


Northeast 


38.1 


15.5 


North Central 


38.9 


14.2 


Federal 
District 


43.1 


20.8 


Central 


38.5 


13.9 


South Central 


33.7 


10.7 


South 


37.2 


25.1 


Mexico Total 


38.3 


14.4 



Table 6. Smoking Among Women in the U.S.- 
Mexico Border 

>- Non-Hispanic 31.6 

>■ Mexican- American 18.5 

Source: 1979 data, by Smith, Warren, Garcia-Niinez, 
1983 

(U.S. Department of Health and Himian Services, 
1992) 



Source: PAHO, 1992 

Table 5: Prevalence of Exposure to Environmental 
Tobacco Smoke Among Non-smokers by Region, 
Mexico, 1988 



Region 


Prevalence of Passive 
Smoking % 


Northwest 


28.2 


Northeast 


31.1 


North 
Central 


31.3 


Federal 
District 


32.7 


South 
Central 


29.2 


South 


25.1 


Mexico 
Total 


31.5 



Source: PAHO, 1992 



Smoking 



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'i 



REFERENCES 



Pan American Health Organization. Tobacco or U.S. Department of Health and Human Services. 

Health: Status in the Americas . Washington, DC: Smoking and Health in the Americas . Atlanta, GA: 

PAHO, 1992. U.S. Department of Health and Human Services, Public 

„. ^ ^ , ^^.,.^„ ^^,., Health Service, Centers for Disease Control and 

Pierce J, Goodman J, Gilpm E, Berry C. Technical _, . xt ^ i /-. . ^ /-.i. • t^- 

' , ' , ~. ;~ Prevention, National Center for Chrome Disease 

report on analytic methods and approaches uSed m the _, ^. , .. - , .. ^. _ __ _, , . 

ZrZ 7; TTTZ '■ mnn infM r. Z ^ Prevention and Health Promotion, Office on Smokmg 

Tobacco Use m California 1990-1991 Report . San , .- ,^, . _ _ . 

r~ ~~ — ~~ and Health, 1992. 

Diego, CA, 1992. 



I 



Page 40 Smoking 



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1 



TOBACCO USE PREVENTION 

IN THE LATINO COMMUNITY: 

THE POR LA VIDA 

"LUCHANDO" PROJECT^ 

Lori McNichoias, M.A., R.D. 

Karen Senn, Ed.D. 

Ana M. Navarro, Ph.D. 

Bea Roppe 

San Diego State University 

ABSTRACT 

This paper presents the results of an evaluation of a 

tobacco use prevention program for Latina women 

that enlisted lay educators to disseminate 

information via their own social networks (Figure 

!)■ 

Methods 

Program goals and objectives targeted both Latina 
women and Latino families as a whole (Figures 2 
and 3). Design of the intervention followed the Por 
La Vida model for health promotion (Navarro, 
Senn, Kaplan, et al; 1995) (Figure 4). Lay 
community workers (consejeras) were recruited and 
trained to conduct educational group sessions 
(Figure 5). Curriculum development followed an 
instructional systems learner-based design (ISD) 
model (Dick & Carey, 1985) (Figure 6) and 
resulted in a seven session bilingual 
Spanish/English facilitator's manual. Content 
included the dangers of smoking, secondhand 
smoke, family communication, community 
empowerment and anti-smoking activities for 
participants' children (Figure 7). Session 
participants were assessed pre and post-intervention 
with a random sample follow-up at approximately 
one year post-intervention. 



'This project was funded by the Tobacco Tax Health 
Protection Act of 1988, Proposition 99, California 
Department of Health Services — Tobacco Control 
Section, Contracts #90-10958 and #92-15438. 



Results 

Demographic data at pretest generated a profile of 
program participants (Figure 8). Repeated measures 
analyses of pre and post-questionnaires indicated 
significant changes in the number of participant 
smokers and the participants' knowledge and 
attitudes (Figures 9 and 10). Participants expressed 
intent for both individual and group level actions 
against tobacco use (Figures 11 and 12). 
Furthermore, follow-up at one year post- 
intervention for this intent revealed significant 
compliance with original intent (Figure 13). 

Conclusions 

This intervention, which was based on the Por La 
Vida model, mobilized social networks to transmit 
knowledge and foster advantageous behavioral 
changes^ This suggests that community-mediated 
programs can help to overcome the social norm of 
smoking as an accepted practice, promoting 
individual, group, and community actions toward a 
nonsmoking environment. 

Figure 1 . Luchando Contra el Uso de Tabaco 
(Fight Against Tobacco Use) 

5^ 1990-1994 

>" South San Diego County 

> 40 consejeras 

> 600 direct participants 

> 35 schools, churches, comm. centers 
5* 275 educational sessions 

> 2,400 indirect participants 

Figure 2. Program Goals 

>■ Reduce tobacco use among Latinas in San Diego 

County 
5» Reduce exposure to tobacco smoke among Latino 

families in San Diego County 

Figure 3. Program Objectives 

> Develop culturally appropriate health promotion 
model for the Latino community 

>* Develop bilingual, culturally appropriate educational 
materials 

> Recruit & train Latinas as group leaders 
>> Conduct educational program for Latinas 

Figure 4. The Por La Vida Model 

> Identifies & tiains local women as group leaders, 
known as consejeras 

> Recruits community women into groups via the 
naturally occurring social networks of the consejeras 



Smoking 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



i 



> Allows for the development of leamer-oriented 
educational materials, using social learning theory & 
empowerment education 

> Supports child care services 

Figures. LaConsejera 

> Lives in the neighborhood 

3> Seen by others as an information source 
>► Committed to improving her community 
^ Has extensive existing social networks through 
which she recruits participants 

Figure 6. Los Materiales Educativos 
(Educational Materials) 

> Involvement by the community to determine 
educational objectives 

> Bilingual, side-by-side Spanish-English 

> Easily mastered by consejeras and their participants 

> Professional design with low literacy format, limited 
handouts 

> Address affective and cognitive needs 

Figure 7. Las Sesiones de "Luchando" (The 
"LucHANDO" Sessions) 

>■ 1 — Introduccion (Introduction) 

> 2 — Los Peligros de Fumar (The Dangers of 
Smoking) 

> 3 — Entre Padres e Hijos (Between Parents and 
Children) 

> 4 — ^Sabe en donde anda el Tabaco? (Do You 
Know Where the Tobacco Is?) 



> 5 — Para Seres Queridos con Carino (For Loved 
Ones with Love) 

> 6 — A la Lucha (To Struggle) 

> 7 — Animandose a Todas (Cheering up Everyone) 



Figures. Baseline Data 



Age 


Median = 35 years 


Language at home 


Spanish = 92.5% 


Country of birth 


Non-U.S. = 91.4% 


Education 


Median = 8 years 


ETS* exposure 




Not 




Exposed 





56% 




Smoker 
13% 



Exposed 

at Home 

31% 

*ETS = environmental tobacco smoke 



Figure 9. Outcomes-. Knowledge 



Secondhand smoke is harmful' 



Smoking Increases blood 
pressure* 



Chewing tobacco stains teeth* 



Chewing tobacco causes 
dental problems* 




20 



80 



40 60 

Percentage 

Pretest (N=587) □ Post-test (N-508) 



100 



(* denotes p<.02) 



Page 42 



Smoking 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



I 



Figure 1 0. Outcomes-. Knowledge 



Smoking increases cancer risk* 



Smoking Is addictive* 



Smoking Is relaxing* 



It Is okay to smoke for 1 or 2 
yaars* 




20 



80 



40 60 

Percentage 
Pretest (N =587) n Post-test (N=508) 



100 



(* denotes p<.02) 

Figure 1 1 . Outcomes-. Behavioral Intent- Group 



R«fu«« to patronix* storvs with 
clflarvtt* machlnvs 



Tak* a community poll 



Writ* lattars to local political 
laadara 



Patltlon to ramova cigaratta 
machlnaa 



'■■"" ' " *"'"""""'"'"""f 




W^.s^'"', ( rv^ I*,'*;* /^^#^ w rt <,'^-*^* ' 




r H 60.3 


Jl 


r~^ .^^iK 


^^^^^^Qf--^'" B S7.7 


^ 








1^^' " """" W ''■' 



20 40 60 

Percentage 

El Plan de Accl6n (Action Plan) (N=471) 



Figure 1 2. Outcomes-. Behavioral Intent- Indiv. 



Not start smoking (nonsmokers only) 
QuH smoking (smokers only) 

Help someone quit smoking 

Ask others to not smoke Inside the 
house 

Place "Hogar Sin Humo" window 
sticker 

Write to magazines with tobacco ads 

Teach a class on the dangers of 
tobacco 













\ " 


■ CO « 


^^^^^ 




1 


■ 52.9 



20 



40 



60 



80 



100 



Percentage 
Plan de Accl6n (N=471) 



Smoking 



Page 43 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



Figure 1 3. Outcomes-. Behavior Intent- indiv. Follow-up 



Not start smoking (nonsmokers 
only) 

Quit smoking (smokers only) 



Initiate house rules for 
smokers 

Help someone quH smoking 

Ask others to not smoke Inside the 
house 

Place "Hogar Sin Humo" window 
sticker 

Write to magazines with tobacco ads 

Teach a class on tlie dangers 
of tobacco 



62.5 



ni,.j,ii,„jji,'M.jar.m.r 



■ 79.8 



181.1 



^77.5 



P91.5 



'82.5 



83.7 




Plan de Acci6n (N=471) D Follow-up Sample (N=80) 

(Action Plan) 



Dick W. and Carey, L. (1985). The Systematic Design of 
Instruction . Scott, Foresman and Company, Glenview, 
Illinois, 277 pp. 

Navarro, A. M., Senn, K. L., Kaplan, R. M., McNicholas, 
L., Campo, M. C, and Roppe, B. (1995). 



Por La Vida Intervention Model for Cancer Prevention in 
Latinas. Journal of the National Cancer Institute 
Monographs . 18 , 137-145. 



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1 



REPRODUCTIVE HEALTH 



U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



SEXUALLY TRANSMITTED 
DISEASES IN ADOLESCENTS 

ENFERMEDADES DE 

TRANSMISION SEXUAL EN 

LOS ADOLESCENTES 

Licenciado Gabino Hernandez Villarreal 

Hospital Universitario 

Calle Primera No. 809 

Cd. Guadalupe, Nuevo Leon, Mexico 

ABSTRACT 

Objective 

The objective of this paper is to reflect on, analyze, 

and raise awareness about the damage caused by 

sexually transmitted diseases in adolescents and to 

provide special information to vulnerable groups in 

this stage of life. 

Description 

This paper provides information on prevention, 
treatment, follow-up, and education about sexually 
transmitted diseases, specifically about avoiding 
short-term and long-term complications and 
spreading the diseases. It reviews the factors 
associated with STDs in adolescents and establishes 
control strategies, focusing on the affected 
population, who have most need of us because of 
their scarce resources and lack of information. 

As statistics rise each day, we need better strategies 
to control the diseases and coordinate the efforts of 
all those who work to encourage good health in 
others. 

Tasks 

Our tasks include implementing prevention and 
treatment programs with the necessary support to 
make services accessible and available. We looked 
at the following: sexually transmitted diseases in 
adolescents; the increase in incidence at the world 
and regional levels; prevention, treatment, and 
education about these afflictions; and strategies for 
control and follow-up. 



INTRODUCOON 

Los altos porcentajes de las enfermedades de 
transmision sexual son cada vez mas alarmantes; la 
incidencia en la mujer lo indica el niimero cada vez 
mayor de ellas que concurren a los consultorios de 
atencion prenatal, ginecologica o de planificacion 
familiar, donde se observa lo importante del 
problema de las enfermedadas de transmision 
sexual. Es un problema grave de salud publica, 
tanto en los paises desarrollados como en los 
subdesarrollados; asi lo demuestran las estadisticas, 
y la preocupacion general es evitar el avance, 
aplicando mayor esfuerzo en las medidas 
preventivas en la poblacion joven: tratamiento, 
seguimiento, educacion y orientacion. 

Proposito 

Analizar, reflexionar y concientizar a la poblacion 
afectada de los estragos que causan las 
enfermedades de transmision sexual, tanto en 
hombres como en mujeres, pero preferentemente en 
la poblacion mas vulnerable: los adolescentes. 

Estadisticas 

Datos de la OMS nos muestran que diariamente, a 
nivel mundial, se infectan con una o mas de estas 
enfermedades de transmision sexual un numero de 
685,000 personas aproximadamente, y que 
anualmente se registran 250 millones de casos 
nuevos. Las mas afectadas son las mujeres; por 
ejemplo, del total de casos de infeccion por 
clamidida, el 70 por ciento son mujeres y el 30 por 
ciento son hombres, los cuales pueden ser 
asintomaticos, asi como el 30 por ciento de las 
mujeres y el 5 por ciento de hombres infectados con 
gonorrea. 

Ahora, el por que de esta platica se enfoca hacia la 
poblacion joven; la Revista "Population Reports" 
(serie 1.L.9, Junio 1993) nos informa que las tasas 
elevadas de enfermedades de transmision sexual 
fueron registradas por un estudio realizado en el 
Hospital Nacional Kenyatta de Nairobi, donde el 23 
por ciento de las mujeres de 15 a 19 ailos de edad en 
control prenatal sufrian de gonorrea, clamidia o 
herpes. En los EEUU, las mujeres de 15 a 19 aiios 
presentaban la incidencia mas alta de gonorrea, y los 
varones de 15 a 19 anos de edad ocupan el segundo 
lugar de todos los grupos de edad en cuanto a 



Reprocuctive Health 



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I 



incidencia de gonorrea. Estamos hablando de una 
poblacion vulnerable a la que debemos dirigir 
nuestros esfuerzos para evitar este gran problema, 
ya sean paises pobres o desarrollados. 

En este estudio se atendieron a 1,360 pacientes en la 
Clinica de Enfermedades de Transmision Sexual, de 
los cuales el 8.5 por ciento tuvieron menos de 20 
anos, y de ellas el 18.9 por ciento tenian 
antecedentes de una enfermedad transmitida 
sexualmente. 

La patologia mas frecuente fue la cervicovaginitis . 
15 casospor: 

5^ Candida 

• Gardnerella 

• Ureaplasma 

El 60 porciento de los adolescentes buscaron 
atencion medica tardiamente, pues manifestaron 
tener mas de 30 dias con sintomas, y en los casos de 
embarazo (69.8 por ciento) su visita al medico no 
occurio sino hasta el tercer trimestre, lo cual es 
congruente con el habitual retraso de este tipo de 
pacientes para buscar la atencion medica. 

Las que presentaron cervicovaginitis refirieron tener 
mas de una pareja sexual. 

Lo que mas preocupa es el incremento en el niimero 
de casos de SID A, y el niimero cada vez mayor de 
adolescentes sexualmente activos, usuarios de 
drogas y portadores de enfermedades de transmision 
sexual (ETS). Ocupamos el tercer lugar en casos de 
SIDA en America, despues de los EE.UU. y Brasil, 
y el decimo quinto lugar a nivel mundial, 
enfatizando que el 16.6 por ciento son menores de 
24 anos de edad. 

En el Estado de Nuevo Leon se han registrado en un 
aiio (Enero 1993 - Enero 1994) 17,304 casos de 
enfermedades de transmision sexual, siendo la de 
mayor incidencia la candidiasis urogenital con 
9,052; el segundo lugar lo ocupa la gonorrea en 
poblacion abierta. 

Estudios realizados por el Programa UNI-UANL 
(Septiembre de 1993 a Septiembre de 1994) en una 
comunidad urbana-marginada en el municipio de 
Apodaca, N.L., nos mostraron que la poblacion que 
acudio a practicarse el Papanicolaou refirio haber 



iniciado su vida sexual de los 15 a 19 anos de edad, 
esto representa un 65 por ciento de la poblacion 
estudiada (584 usuarios), y las infecciones de mayor 
incidencia fiieron de origen bacteriano, y es esta 
poblacion la que menos acude para su atencion 
medica. 

Otro problema que enfrentan las adolescentes son 
los abortos, que ponen en riesgo su salud. El 
registro que se lleva a cabo en el Servicio de 
Ginecologia del Hospital Universitario de 
Monterrey, N.L. (Junio de 1994 - Junio de 1995) 
muestra que este grupo, en edades de 15 a 19 anos, 
ocupo el segundo lugar de abortos incompletes. El 
primer lugar lo ocupa el grupo de 20 a 24 anos de 
edad. 

Al haber visto un panorama general de lo que ocurre 
con las adolescentes con respecto a este tema, se 
concluye que las ETS, constituyen un grave 
problema con tendencia al aumento entre las ninas 
y las adolescentes. Entre los factores que se cuentan 
esta en primer termino el inicio de la relacion 
sexual (coito) a tan temprana edad terminando en 
divorcios cuyos efectos se sienten principalmente en 
los adolescentes y en los hijos de estos. Las 
enfermedades venereas tradicionales: sifilis, 
gonorrea, chancroide y linfogranuloma, solo 
representan una fraccion de las enfermedades de 
transmision sexual. 

Entre otros factores asociados a las enfermedades de 
transmision sexual en la adolescencia se cuentan: 
>> Malas relaciones con los padres. 
>* Bajo promedio de calificaciones academicas. 

> Autoestima baja. 

5=» Falta de practica religiosa. 

>* Uso temprano de bebidas embriagantes. 

>* Uso de drogas por companeros y amigos, padres o 

familiares cercanos. 
>* Abandono de escuela y trabajar en edad temprana. 

> La pobreza. 

Poblacion afectada: 

>- Estudiantes. 

>* Ninos que trabajan en la calle. 

5> Hogares de areas urbano-marginadas. 

Factores que nos permiten identificar a pacientes 
con riesgo de adquirir enfermedades de transmision 
sexual y donde se recomienda la educacion es en: 



Page 48 



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>* Adolescentes sexualmente activos. 

>* Adolescentes embarazadas y sus contactos sexuales. 

>- Adolescentes con sintomas de enfermedades de 

transmision sexual como: uretritis, cervicitis, 

epididimitis y proctitis. 
>* Niiias prepuberes con vaginitis, disuria o prurito 

perineal. 
>* Adolescentes que viven en grupos o correccionales. 
>" Cualquier nino o adolescente victima de abuso 

sexual, estupro o incesto. 
>" Adolescentes prostitutas. 
>► Adolescentes varones homosexuales. 

Los medicos deberan basar su diagnostico con gran 
rigor en los examenes de laboratorio y compartir la 
responsabilidad con todo el equipo de salud, en la 
busqueda de contactos, educacion y orientacion para 
el seguimiento de cada caso. Hacer hincapie en 
secuelas potenciales a largo plazo de estas 
enfermedades. 

Propuestas Para Posible Soluoon Del Problema 

>■ Escuchar a los Jovenes. Es necesario invitar a los 
jovenes a iniciar junto con nosotros programas para 
su propio beneficio y entonces aparte del exito que 
se obtiene por su participacion, tambien representa 
una gran satisfaccion para los adultos que ban 
vivido esa experiencia. 

> Inter cambio de Ideas: Definitivamente, la 
utilizacion de estas estrategias donde participan 
jovenes y adultos, significara que estos adultos 
seran los proveedores de los servicios de salud que 
escucharan a dichos jovenes y aprenderan de ellos 
lo que tal vez se ha olvidado, proporcionandoles la 
experiencia y conocimientos de nuestra parte y asi 
tratar de resolver en parte sus problemas o que no 



Ueguen a tenerlos. 

> La Persona y su Medio Ambiente: Un enfoque 
integral donde se tome en cuenta a las personas 
adolescentes y no el "problema adolescente" para 
que este enfoque sea mas duradero y eficaz en lugar 
de encontrar soluciones especificas a problemas 
especiflcos, lo que sera mas limitado. 

>" Interrelacionar los Servicios. Tendremos que dar 
prioridad al establecimiento de vinculos o enlaces 
en la propia comunidad; estos podran ser entre las 
personas que trabajan en los Programas de 
Planificacion Familiar, en la Educacion , en la 
Salud Matemo Infantil, de Enfermedades de 
Transmision Sexual y en otros servicios mas que 
logren, en conjunto con los jovenes, establecer 
programas para ellos y que suija verdaderamente 
una "asociacion" donde existan esfuerzos conjuntos 
y asi crear medios formales de cooperacion y que 
sean los jovenes ese enlace natural en la solucion de 
sus problemas. 

Nosotros, los adultos dedicados a mantener la salud, 
ganaremos mucho si permitimos a los jovenes 
instituir una verdadera sociedad con nosotros y 
perderemos mucho si no lo hacemos. Tendremos 
que adecuar la educacion sexual y el suministro de 
anticonceptivos a cada grupo de jovenes sin olvidar 
su escolaridad, condicion social y su cultura, ya que 
estamos bombardeados por la pomografia a traves 
de revistas, peliculas, canciones, periodicos, donde 
se envian mensajes intencionados con el fin de 
vender mercancia y de paso pervertir o de inducir a 
la relacion sexual irresponsablemente. 



Reprocuctive Health 



Page 49 



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1 



EsTADiSTiCAS De PatologIas Mas Frecuentes En La Mujer , De Junio 1 994 A JUNIO 1 995 En El Servioo 
De Ginecolog'ia Hospital Universitario, Monterrey, N.l 



r*"'"'^""--— -.^igUPOS DE EDAD 
PATOLOGfAS ^---~-..___^^ 


15-19 
AlSfOS 


20-24 

AI^OS 


25-29 

AlSfOS 


30-34 

A^OS ; 


35-39 

Al^OS 


40-44 

AlSfOS 


Aborto Incompleto 


101 


131 


50 


40 


15 


7 


Aborto Inevitable 


18 




2 


4 




2 


Aborto Habitual 








2 






Amenaza De Aborto 


7 


6 


1 


1 






Aborto En Evolucion 




3 


2 








Pielonefntis + Embarazo 


10 


7 


1 


2 






H.M.R. 


13 


14 


8 


13 


6 




Embarazo Ectopico 




13 


3 


14 


5 




Mola Hidatidiforme 


2 


1 


6 




2 





FUENTE: Registro Diario de Intemamiento 



N = 512 



Programa Uni-uanl Clinica Universitaria 
Pueblo Nuevo 

Inicio de vida sexual activa de poblaci6n que acudi6 a 



que i 
realizarse el Papanicolaou de Sep. 93- Sep. 94 

0% 



11% 
1% 



64% 




EDAD EN ANOS 

FUENTE: REGISTRO DE CITOLOGIA 



H<14 

n30-34 
■20-24 
b25-29 
■ 15-19 
n 35-39 



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BIBLIOGRAFIA 



Botella LJ. Enfermedades de Transmision Sexual . Ed. 
Salvat, 1988, Barcelona, Espana. 

Control de enfermedades de transmision sexual. 
Population Reports, Serie L, No. 9, Baltimore, Johns 
Hopkins, School of Pubhc Health, Junio de 1993, USA. 

Family Health Intemacional. "Network" en espanol, 
USAID, Vol. 9, No. 3, JuHo de 1994, EUA. 

Qrgano de la Academia Nacional de Medicina. "Gaceta 
Medica de Mexico," Vol. 129, No. 1, Enero-Febrero, 
Mexico, 1993. 



Ortega HH. Salud Fronteriza, OPS/OMS, Vol. 1 1 1, No. 
2, EUA-Mexico, 1987. 

Schwarz RH. Clinical obstetric and ginecology. Vol. 6, 
No. 1, Marzo de 1983, New York. 

Tovar TMC. Enfermedades de Transmision Sexual . Ed. 
XYZ, 1988, CaU Colombia. 



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A PREGNANCY PREVENTION 
PLAN FOR HIGH-RISK YOUTH 

Sheila Fitzpatrick, ACSW 

The Casey Family Program 

San Antonio Division 

ABSTRACT 

This paper addresses the components of an effective 
pregnancy prevention program focused on a high-risk 
population of youth in long-term foster care in the 
Casey Family Program, San Antonio Division. This 
pregnancy prevention program is a multi-impact, 
ongoing approach aimed at the prevention of 
pregnancy, sexually transmitted diseases (STDs), and 
unwanted sexual experience. Youth and foster 
parents are educated on birth control methods, the 
effects of STDs, risk reduction, the reproductive 
process, and early signs of pregnancy. Highlights of 
the program include incorporating reproductive 
health issues into every child's plan of service, 
including and educating foster parents in the process, 
and increasing staff skills in addressing sexuality 
issues with foster parents and youth. 

The Problem 

According to the Child Welfare League of America, 
research indicates that young people in foster care are 
at high risk of engaging in early unprotected sexual 
activity and experimenting with alcohol and other 
drugs. A 1986 survey compared young people in 
foster care with their counterparts who were not in 
foster care and found that youngsters in foster care 
were more likely to have had sexual intercourse, 
twice as likely to have been pregnant, less informed 
about human sexuality and birth control, and less 
likely to use contraceptives (Polit, White, and 
Morton, 1987). 

Increasing evidence indicates that adolescents who 
were sexually abused are at higher risk for sexual 
promiscuity and maladjustment, which may lead to 
early pregnancy. Dr. Nancy Kellogg recently 
conducted a research project with adolescents in the 
Northside School District, San Antonio, Texas, 
asking them about unwanted and wanted sexual 
experiences. She found that early family 



dysfunction, including abuse, neglect, and 
substance abuse, was directly related to the time of 
an adolescent's first wanted sexual experience. 

Further statistics indicate that adolescents who are 
involved in the child welfare system display a 
dangerous combination of characteristics— they are 
more likely than their peers to have sex and are less 
informed about sexuality and family planning. In a 
national survey of child welfare caseworkers, 
conducted by the above -referenced authors, it was 
revealed that most agencies have not developed 
substantive responses to the sexuality needs of their 
clients and that most caseworkers are not 
comfortable dealing with these subjects. Less than 
half of the 761 respondents reported that they 
usually ask foster children about previous or current 
sexual activity. 

Components of an Effective Pregnancy 
Prevention Plan 

5> The Child Welfare League of America 
recommends the following three-pronged 
approach: 

• Develop policies that address adolescent 
sexuality and family planning for youth and 
incorporate these policies into the case plan. 

• Offer training for caseworkers, foster parents, 
and administrators on sexuality and family 
planning services. 

• Provide opportunities for youth in out-of- 
home placements to participate in community- 
based programs. 

Experts have identified three major program 
strategies that can help prevent adolescent 
pregnancy: 1) provide information or influence 
attitudes about sexual behavior; 2) increase access 
to contraceptives for sexually active teens; and 
3) enhance life options as an alternative to early 
pregnancy and parenting. After reviewing 
numerous prevention programs, researcher and 
author Joy Dryfoos developed a list of 
characteristics of successful pregnancy prevention 
programs. These characteristics include: 
>* Comprehensive programs — No one intervention 
is enough in itself to prevent adolescent 
pregnancy. A multiple impact approach is 
needed. 
>" Intensive programs — Children should be exposed 
to the programs early and then consistently 
throughout adolescence. Youth need to hear 



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about alternatives frequently over an extended 

period of time. 
>^ Parental involvement — Parents and other family 

members should be involved as role models. If 

parents are not involved, other adult role models in 

the community should be used. 
>> Provision of social skills — Youth need to obtain 

the skills that will help them participate in the 

larger society. 
>- Connection to the world of work — Youth will 

have increased self-esteem and more structured 

time when exposed to job opportunities. 
>* Confidential access to contraceptive services — 

Youth who are sexually active need access to 

services that provide information and make means 

of contraception available. 
>> Community collaboration — Agencies should join 

with other agencies and organizations to provide a 

wide range of services. 
5i^ Involvement of schools — Many of the programs 

can be offered in the schools. 
>> Early intervention — Programs should start by the 

later grade-school years because many pre-teens 

are experimenting with sex. 
>> Male involvement — Programs should appeal to 

young men and have male counselors if possible. 

The Casey Family Program 

The Casey Family Program (TCFP) is a licensed, 
privately endowed foster care agency designed to 
provide quality, platmed, long-term foster care for 
children and youth who have no family with whom 
they can live and whose adoption is improbable. 
These are children who have experienced serious 
abuse, neglect, and other problems. Their growth 
experiences have been interrupted by the instability 
of their home life. To further compound this 
problem, they usually have had multiple placements 
before referral to TCFP. 

The program originated in Seattle, Washington, in 
1965 when Jim Casey, the fotmder of United Parcel 
Service (UPS), contacted the Child Welfare League 
of America to discuss his plans to formulate 
guidelines for a foster care program for children 
without family resources. The program equips 
young people with the skills to form and sustain 
significant positive relationships, effectively parent 
their own children, participate responsibly in their 
communities, sustain themselves economically, and 
provide support to those children and youth who will 
follow them in the program. There are now divisions 



in 18 states serving more than 1,000 children 
nationwide. 

TCFP adopted a communicable disease policy for 
the entire agency in 1993. The rationale for this 
plan was that communicable diseases, especially 
sexually transmitted diseases (STDs), are a 
significant problem in the country as a whole, and 
specifically with the youth in our care. The rising 
incidence of unplanned pregnancies, STDs, and 
intravenous drug use is affecting the children in our 
care. The focus of the Casey policy is to prevent 
these whenever possible through educating youth, 
foster parents, and staff. The following general 
guidelines were adopted: 

>> All youth in TCFP will receive age-appropriate 
education in human growth and development, 
sexuality, family planning, infection-control 
procedures, reproductive health services, and 
cultural perspectives on health issues. Medical 
services to youth will include risk assessment and 
referral. The needs of each individual child will 
be addressed in the child's service plan. 
Abstinence and learning assertive skills to deal 
with sexual overtures and peer pressure will be 
stressed. 
>' All foster parents will be required to attend 

annual training on talking to children about their 
changing bodies and issues of sexuality, as well 
as communicable disease issues. Foster parents 
are required to participate in the child's plan for 
prevention of communicable diseases and/or 
pregnancy. 
5=* All professional staff will be required to attend 
updated training once a year. Social workers are 
expected to maintain a knowledge base sufficient 
to help foster families and youth struggle with the 
issues relating to communicable disease. 

Goals for Youth 

>- Females 14 and older should have a 

gynecological exam that includes the discussion 
of their sexual activity and an assessment of the 
need to discuss birth control and safe sex 
practices. In some instances, if a child is clearly 
not sexually active, this can be postponed. 

>' Males 14 and older should have a discussion of 
adolescent sexual activity and an assessment of 
the need to discuss birth control and safe sex 
practices. 

>" During the plan of service and plan of service 
review done with youth and their foster parents, 
an assessment should be made about the child's 



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need for knowledge and/or skills regarding proper 
sanitary practices, maintaining healthy bodies, 
spread of communicable diseases, knowledge of 
human sexuality, making healthy choices, and 
caring for self 
>► TCFP should provide age- and developmentally 
appropriate training for youth, based on 
recommended guidelines. 

Foster Parents 
Outcomes desired include: 

> Foster parents will be aware of their particular 
child/children's needs regarding the previously 
mentioned developmental milestones and will 
cooperate in helping to formulate specific plans for 
their children. 

>" Foster parents will be kept abreast of the changing 
knowledge of health care issues that relate to 
families and children, specifically those connected 
to health and sexuality concerns. 

>> Foster parents will be able to discuss issues of 
health standards and sexuality in productive ways 
with youth in their care. 

Goals 

> Prospective foster parents will learn about the 
TCFP health and prevention policy during the 
study process and in their preservice training. A 
copy of the policy should be in the "PRIDE" 
Handbook for every PRIDE participant/couple. 
The Foster PRIDE/Adopt PRIDE program was 
developed at the request of foster parents in 
Illinois. The program quickly became a 
collaborative effort which included representatives 
of many agencies and the Child Welfare League of 
America. The goals of PRIDE were to: 1) address 
the learning needs of new and experienced foster 
parents, 2) have an evaluation component, and 3) 
lead either to a certification process or another 
means of recognizing the professional role of foster 
parents. Five competencies are addressed in the 
training, several of which include the need for 
foster parents to be acutely aware of their child's 
developmental level, including as sexual being, and 
to respond to the youth's needs in a realistic, safe, 
and nurturing manner. Prospective foster parents 
should be willing to support the agency's policy by 
getting children to the training and/or other events 
and by attending the training themselves, and 
helping youth access the medical and supportive 
services necessary to meet the goals stated above. 

>- Foster parents, the social worker, and youth will 
dialogue in planning services that will help 
children reach developmental milestones having to 



do with health and sexuality. This would include 
a discussion with the foster parents regarding the 
milestones that the division has adopted as 
indicators to meet the desired outcomes. 

>* Foster parents will receive training to help them 
meet the outcomes desired. This training will 
include at least one 3-hour session with an outside 
resource speaker on "Communicating with Kids 
about Sex," talking in cluster groups, father-son 
night, mother-daughter night and articles in the 
newsletter alerting foster parents to other training 
opportunities in the community. 

>^ Foster parents will be given written information 
that will help them communicate with their 
children about this subject. 

Staff 
Outcomes desired include: (1) The director, social 
work supervisor, foster home developer, and social 
workers will be aware of the need for preventive 
services to guide youth toward making safe 
decisions regarding their bodies and their lives. 
(2) Each professional staff person will increase his/ 
her knowledge and skills in identifying youths' 
developmental needs in regard to communicable 
disease, discussing issues with youth and foster 
parents, and identifying and using outside resources 
when necessary. 

Community 
Outcomes desired include: (1) Physicians who treat 
our youth will be knowledgeable of the needs of our 
youth in relation to regular health care and risk 
prevention and prevention of STDs and teen 
pregnancies. This includes an understanding that 
many foster children are sexually abused and in 
need of sensitive services. (2) Staff of TCFP, San 
Antonio Division, wall be aware of the resources in 
the community and identify those most pertinent 
and helpful to our goals. (3) Staff at TCFP will 
take an active part in the community effort to 
prevent pregnancy and STDs and will provide 
ongoing services to persons with AIDS. 

Barriers 
Foster parents often resist the agency providing 
reproductive health information to youth. 
^ Their main concern is that the values of the foster 

family such as no premarital sex or no use of 

birth control will not be upheld. 
>- Another concem is that the teaching of birth 

control methods is an open invitation for youth to 



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have sexual relations. 
>" Sometimes, because of cultural tradition, foster 
parents feel very uncomfortable discussing the 
issues. 

Adolescents are also resistant to hearing about and 

discussing information regarding sexuality. 

Ss' Adolescents tend to feel invincible: "That won't 

happen to me." 
>- Adolescents are concerned with privacy issues. 

> Adolescents are often embarrassed in discussing 
the information. 

^ Adolescents want to appear "cool" and 
knowledgeable to their peer group. 

^ High-risk adolescents in foster care frequently have 
clinical issues that have not been resolved, often a 
result of previous sexual abuse. Their images of 
themselves as sexual beings are often distorted. 
High-risk youth in foster care also often engage in 
self-destructive behavior due to low self-esteem. 

• Staff, as well, also constitute a barrier in service 
delivery. 

• Staff working with youth have to overcome 
their own discomfort in discussing sexual issues 
with youth and foster parents. 

• Staff often have varying viewpoints on such 
value-laden issues as providing birth control to 
teenagers and discussing abortion as one 
alternative to a pregnant teen. 

• Staff may also feel uncomfortable discussing 
sexuality with an opposite sex child. 

Table 1 . Program Highlights 

>■ Incorporating reproductive health issues into every 
child's plan of service. 

> Including foster parents in the meeting with their 
foster children when discussing sexuality issues. 

> Educating foster parents about the current trends in 
sexuality, STDs and teen pregnancy, including a 
foster parent handbook. 

>* Increasing staff skills in addressing sexuality issues 
with foster parents and youth by bringing in 
experts with updated information and having 
continued dialogue regarding agency policies and 
values. 

>* Including sexuality issues in existing groups, such 
as the middle school socialization group which 
meets monthly. 

>* Age-grouping sessions of youth with a health 

consultant who networks with existing resources ia 
the community. 

>- Ongoing, frequent addressing of salient issues in 
multiple modalities, such as group work, training, 
one-on-one with social worker/therapist, and 



medical services. 
> Cultural sensitivity through understanding the 

values of different cultures and the use of Spanish 

language materials. 
>* Networking with health providers who are 

familiar with and sensitive to the foster youth 

population. 

Conclusion 

Pregnancy prevention involves a determined 
approach over time. The program should start early 
in a child's life and continue throughout the child's 
stay in care. Focusing on the 'Vhole child" and 
his/her needs to belong, to achieve, and to be 
respected as an important, unique individual will 
reduce the risk of the child engaging in high risk 
behavior to get his/her needs met. This takes the 
commitment of people working together for the 
good of youth— the youths themselves, foster 
parents, social workers, teachers, medical 
persormel, mentors, and other adult role models. 

Outcomes Desired for Elementary School 
Children 

>- The children will— 

• Know safety rules and what to do in case of 
emergency 

• Understand that he/she has a right to privacy 
and not to be touched in private places 

• State personal needs clearly and assertively 

• Regulate impulsive behavior 

• Have cooperative relationships with fiiends 
and others 

• Be able to identify resources, including 
parents, peers, school officials, nurses, and 
social workers, who can be asked questions 
about sexuality and relationships 

• Respond appropriately when introduced to 
strangers 

• Respect rights of others 

• Describe the reproductive process in basic 
terms 

• Understand that there are consequences to 
sexual behavior 

• Understand that there are negative 
consequences to using drugs and alcohol. 

Outcomes Desired for Middle School 
Children 

y^ The children will— 

• Understand the physical and emotional 
changes that occur during puberty 

• Have realistic ideas about body image and 



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explain the effects of eating disorders 

• Identify behavior related to and effects of 
alcohol and drug use 

• Cite examples of legal drugs that can be 
dangerous 

• State the problems surrounding teen pregnancy 

• Identify pregnancy symptoms 

• Identify techniques in setting limits with others 
who pressure him/her to experiment with drugs 
and alcohol 

• Identify techniques in setting limits on sexual 
advances; explain the concept of sexual consent 

• Follow common safety practices when not 
under adult supervision, for example, going to 
malls in groups, going to the bathroom together 
at the movies 

• Explain in own words the reasons for laws 
regarding hitchhiking and curfew 

Outcomes Desired for HIGH School Children 

>■ The children will— 

• Identify and be able to get to the nearest 
emergency room, clinic, and hospital 



• Make and keep appointments with doctor, 
dentist, and counselor 

• Cope with sexual feelings for people of same 
or opposite sex 

• Make responsible decisions concerning 
personal sexuality and sexual behavior 

• Practice safe sex, if sexually active, to prevent 
AIDS and STDs 

• If sexually active, practice birth control 

• Identify and state methods for avoiding 
sexually transmitted diseases 

• Identify when and where to get help for drug 
and alcohol-related problems 

• Discuss the advantages and disadvantages of 
and the factors influencing a successful 
marriage 

• Analyze and explain his/her own personal 
developmental needs prior to becoming a 
parent 

• Explain the importance of family planning 



REFERENCES 



Polit DF, White CM, Morton TD. Sex education and 
family planning services for adolescents in foster care. 
Familv Planning Perspectives . 1987;19(18). 

Dryfoos, JG. Adolescents at risk: a summation of work in 
the field— programs and policies. J. Adolesc Health . 
1991;12(8), 630-37. 



Foster PRIDE/Adopt PRIDE, Casey Family Program, 
Seattle, Washington, 1994. 



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ADOLESCENT PREGNANCY: 

AN ANALYSIS OF THE FAMILY 

CONTEXT AND SEXUAL 

DEVELOPMENT 

Rosario Roman Perez 

Esthela Carrasco Corona 

Elba Abril Valdez 

Center of Research on Food 

and Development 

ABSTRACT 

This study describes and analyzes the social and 
familial context in which adolescence takes place 
and the factors that could postpone pregnancy. We 
used an ethnographic approach with a case study 
technique, examining three families with an older 
daughter who was a teenage mother and a younger 
daughter who has never been pregnant (see 
Table 1). Further research is needed to analyze the 
role of education, free time, and job opportunities. 

Introduction 

Much of the research addressing adolescent 
pregnancy has defined it as a public health problem 
and ascribed to it expressions such as "social 
deviance" (Klein, 1978) or "problem of social 
inequality" (Pantelides and Cerruti, 1992). This 
assumption is based on the acceptance without any 
questioning of the negative consequences of early 
pregnancy and the universal recognition of 
adolescence as a concept, with little consideration 
of the social context. 

Research evidence of adolescent pregnancy risks 
can be grouped into three kinds of studies according 
to the consequences they document— biological, 
social, and psychological (Figure 1). Among the 
first, we found problems of toxemia, preeclampsia, 
anemia, low birth weight, neonatal death, and 
abortion (Ortigosa, Carrasco, and Gonzalez, 1992; 
Singh and Wulf, 1990). At the social level, 
dropping out of school, early participation in the 
labor force, impoverishment, and high fertility rates 
(Ortigosa, Carrasco, and Gonzalez, 1992; Buvinic, 
Valenzuela, Molina, and Gonzalez, 1992) have 



been documented. The psychological studies 
indicate problems of stress, low self-esteem, 
suppression of identity, and even suicide and 
postpartum psychosis (Black and DeBlassie, 1985; 
Romig and Bakken, 1990). 

According to Nathanson (1991), it is taken for 
granted that pregnancy in adolescence is a problem. 
However, it is not clear why and for whom 
pregnancy is a problem or what the factors are that 
make it a problem. To understand how adolescents 
get pregnant or how they may postpone pregnancy, 
we analyzed their family and social context. Our 
aim was to identify what the setting events are that 
prompt or delay pregnancy in women younger than 
19 years old. 

Method 

We worked with the case study technique. We 
interviewed the mothers and daughters of three 
families with low socioeconomic status. The 
families had at least one older daughter who got 
pregnant when she was an adolescent and one, 
younger, who had not. They all lived in an urban 
area in northwest Mexico (Figure 2). 

Families were recruited from those we had worked 
with in our previous studies with pregnant 
adolescents. The mothers and their daughters 
provided informed consent. Interviews concerned 
how they experienced adolescence, their interaction 
with males, and the family context and 
relationships. 

Results 

In the context we studied, adolescence is expressed 
for girls as a time of changes. The points of 
departure they perceive are the celebration of their 
15 years' party, the first menses, and the change 
from elementary to secondary school. Adolescence 
is also a time for entertainment and parties 
regardless of the burden the adolescents may have 
of household activities and caring for infants. 

The adolescents reported other changes associated 
with their body, such as their breasts growing; their 
emotions, such as feeling like a child or a young 
adult; and their perceptions, such as being aware of 
how adults perceive them. Adolescence also 
represents for these youngsters a time for courtship 
and having boyfriends. 



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When a girl has a boyfiriend, he asks the girl's 
parents for their consent to visit her at home. 
Usually the parents agree, but at the same time they 
increase their control over the girl and her 
boyfriend's going out. A younger sister or brother 
or another female goes everywhere with the couple 
as a chaperon to take care of them. 

The ideal of the adolescents and their niothers is to 
get married in a religious and legal ceremony, 
"casarse bien," dressed in a white dress. Not many 
of them achieve this ideal. Usually they get 
pregnant out of marriage and live in a consensual 
union. 

In our study, the adolescents tended to get pregnant 
before they dropped out of school. The pregnant 
girl did not express interest in restarting her 
education or looking for a job in the future. The 
nonpregnant younger sister remained at school or 
was working at the age when the older sister got 
pregnant. 

The nonpregnant adolescents thought that having a 
baby would restrain them from education, 
employment, and frm. At that moment, that reason 
represented a good motivation to delay pregnancy. 
On the contrary, for the now-pregnant adolescents 
who dropped out of school even before meeting 
their boyfriends, education or employment was not 
an aim. After dropping out of school, they 
remained at home, waiting for their "prince," with 
no clear definition of life plans. 

If the boyfriend was a young man acquainted with 
the girl's family (a neighbor or a sister's or 
brother's friend), the young couple has 
opportunities to be alone at their parents' homes. 
Such a situation makes the first sexual intercourse 
possible. The nonpregnant adolescents had stories 
of brief periods of dating with boyfriends unknown 
to their parents; they had few opportunities to be 
alone with their boyfiiends. 

The pregnant adolescents' mothers also tended to 
get pregnant when they were adolescents. Atkin 
and Givaudan (1989) and Presser (1976) mentioned 
a close relationship between the adolescent's sexual 



and reproductive behavior and that of her 
mother. An explanation of this relationship 
possibly could be found in the girls' social 
learning process and the role of observation and 
imitation. 

In family interactions, sexuality is a taboo. When 
the first menses appears, the mothers alert their girls 
about pregnancy, but they do not tell them how to 
avoid it. The mothers' advice is the imperative 
"take care." The range of meanings for "take care" 
may be wide, including not to have sexual 
intercourse or not to get pregnant out of wedlock 
(Figure 3). 

Among the risk factors or predictors for early sexual 
intercourse in adolescents, the lack of effective 
maternal advice on sexuality was mentioned by 
Ortigosa, Carrasco, and Gonzalez (1992) and Pick 
de Weiss, Rivera, Flores, and Andrade (1987). 
None of our participants received from their 
mothers specific information about this topic. 

Dating, sexual relationships, and pregnancy in 
adolescents are tolerated by the parents, mainly by 
the mother. When the boyfriend accepts his 
fatherhood, pregnancy gives place to the consensual 
union that family members refer to as "marriage" 
(Figure 4). 

The family relationships in our study were 
conflictive, with stories of sexual abuse, drug 
consumption, and violence. The nonpregnant 
adolescents lived with their grandmother or older 
sister for protection and support (Figure 5). 
Whenever the adolescents have problems, they 
leave their homes and look for a "shelter place" with 
other family members living in a different location. 
We think that this support network is important to 
delay pregnancy as it provides the opportunity to 
escape from a difficult environment. 

We have described the family context of pregnant 
and nonpregnant girls. For a better understanding of 
the factors that prompt or delay pregnancy, we 
suggest that fiiture research is needed to analyze the 
role of education, free time, and job opportunities. 



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Table 1. Characteristics of the Participants 



Case 


Age 


Civil Status 


Education 


Mother 


Presnant 
Adolescent 


Noiwreenant 
Adolescent 


Mother 


Presnant 
Adolescent 


Nonpreenant 
Adolescent 


Mother 


Presnant 
Adolescent 


Nonvresnant 
Adolescent 


1 


40 


11 


15 


Married 


Married 


Single 


2 


9 


8 


2 


40 


18 


16 


Married 


Single 


Single 


<6 


6 


6 


3 


52 


19 


18 


Widowed 


Consensual 
Union 


Single 


3 


9 


9 



Figure 1 . Early Pregnancy Risk 




Figure 2. Characteristics of the Pregnant 
Adolescent in an Urban Area of Hermosillo. 
Mexico 

>■ School abandonment before meeting partner 

>* No interest in going back to school 

>* Early pregnancy among other female family 

members 
>" First sexual intercouse was at either her or his 

parents' home 
>» Family and social acceptance of the teenage 

pregnancy 
>* As a means to survive they live at his or her 

parents' home 
^ Conflictive family relationships 
>" No stability in partner's employment 
> No clear definition of life plans 



Figure 3. Communication about sexuauty is 

RESTRICTED 



Menses 
Contraception 
Sexual Relationship 




"Take care!" 



Figure 4. Sexual intercourse associated with-. 

>■ Way to know partner 

>^ Partner's age and his sexual experiences 

>" Time of dating 

>> Degree of family conflicts 

>* Having a place and a person for protection 

Figure 5. Mother's education and support 

associated with early prenatal CARE: 

>■ Few reports of pregnancy and deUvery problems 



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Atkin ZLC and Givaudan M.M. Psychosocial profile of 
pregnant Mexican adolescents. Selected Themes in 
Human Reproduction . Samuel Karchmer K.Ed. Mexico: 
National Institute of Perinatology, 1989 pp. 123-133. 

Black C. and DeBlassie R. Adolescent pregnancy: 
Contributing factors, consequences, treatment, and 
plausible solutions. Adolescence . 1985;XX:78 (281- 
289). 

Buvinic M, Valenzuela JP, Molina T, Gonzalez E. The 
fortunes of adolescent mothers and their children: The 
transmission of poverty in Santiago, Chile. Population 
and Development Review . 1992; 18:2(269-97). 

Klein L. Antecedents of adolescent pregnancy: 
Psychological problems and emotional factors. Clinics 
for Obstetrics and Gvnecologv . 1978;4(1 199-1208). 

Nathanson CA. Dangerous passage: The social control 
of sexuaUty in women's adolescence . Philadelphia, PA: 
Temple University Press, 1991. 

Ortigosa E, Carrasco I, Gonzalez A. Socioeconomic and 
educational profile concerning reproduction in 
adolescents. Perinatology and Human Reproduction. 
1992;6:2(70-6). 



Pantelides EA, Cerruti MS. Reproductive conduct and 
pregnancy in adolescents . Argentina: Centre de Estudios 
de Poblacion (CENEP), 1992;47. 

Pick de Weiss S, Rivera AS, Flores GM, Andrade PP. 
What role does the family play in the sexual and 
contraceptive conduct of adolescents in Mexico City? 
Review of Social Psychology and Personality . 1987; 
3:1(1-15). 

Presser HB. Some consequences of adolescent 
pregnancies . Paper presented at the Conference of the- 
National Institute of Child Health and Human 
Development, Bethesda, MD, 1976. 

Romig CA, Bakken L. Teens at risk for pregnancy: The 
role of ego development and family processes. Journal of 
Adolescence . 1990;13(195-9). 

Singh S, Wulf D. Adolescents of today, fathers of 
tomorrow: A profile of the Americas. Editorial. The 
Alan Guttmacher Institute, New York, NY 1990. 



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MATERNAL BEHAVIOR UNDER 

TWO FORMS OF FEEDING: 

BREAST AND BOTTLE 

Rosario Roman Perez 

Cecilia Leyva Hernandez 

Maria Jose Cubillas Rodriguez 

Center of Research on Food and 

Development 

Carretera a La Victoria 

Hermosillo, Sonora, Mexico 

ABSTRACT 

Breast-feeding is recommended for better infant 
nutrition and a higher quahty of interaction between 
mother and child. Using bottles raises the question 
about what changes it introduces in maternal 
behavior. This study recorded the type and number 
of behaviors expressed by mothers who breast-fed 
and those who fed with a bottle. At 7, 45, and 60 
days after birth, episodes were videotaped with 15 
mother-child days with breast-feeding and another 
15 days with bottles. The categories of behavior 
observed were physical contact, verbal 
communication, visual contact, and other 
movements. The form of feeding did not show 
statistically significant differences in maternal 
behavior with the exception of physical contact in 
breast-feeding. The reaction of the mothers to their 
children in this form of feeding was quicker and 
more varied than in those with the bottle. It is 
recommended that this type of observation be 
complemented with qualitative and longitudinal 
data that will permit establishing in greater detail 
the possible effects of the form of feeding on the 
mother-child interaction. 

Antecedents 

Studies about infant feeding indicate that breast 
milk is best for infant development and nutrition 
(De Araujo, Cuotinho, Falcao, and Macedo, 1991; 
Temboury, Otero, Polanco, and Arribas, 1994). 
Breast-feeding promotes the infant's attachment to 
the mother through skin-to-skin contact (Arrieta 
and Cravioto, 1985; Ainsworth, 1986). Breast- 
feeding is also a source of stimulation for the 



newborn. If for any reason mothers bottle-feed, 
there is little empirical evidence about how this 
feeding mode affects the mother-infant behavior and 
attachment. 

There is also controversy on the effects of the lack 
of stimulation for the newborn's psychological 
development. The information about this topic 
generally is narrative and not systematic. The 
limited range of the baby's response that is easily 
measured makes an empirical analysis of mother- 
infant interaction under different feeding modes 
difficult. 

In this work we used a videocamera to register 
mothers' and infants' behavior with both breast- and 
bottle-feeding. 

Objective 

>- To identify and describe mother's behavior for 
two modes of infant feeding at 7, 45, and 60 days 
after birth 

>" To identify and describe infant's behavior for two 
feeding conditions 

Method 

study Participants 

We worked with primiparous mothers, living with 
their partners; all were housewives. The mean age 
of breast-feeding mothers was 20.1 (±2.1), mean 
years of education of 9.2 (±2.2), and mean monthly 
family income of 1 .9 minimum wage (±0.5). Sixty- 
eight percent were married and living in extended 
families. Their infants' mean birth weight was 
3.203 kilograms with a length of 49.63 centimeters. 

Bottle feeding mothers had a mean age of 20.3 
(±2.6), mean years of education 10.0 (±2.2), and 
mean family income of 1.5 minimum wage (±0.4). 
Their infants' mean weight was 3.161 kilograms 
with a length of 49.65 centimeters (Table 1). 
Mothers and child were reported clinically healthy. 
The participation of primiparous mothers ensured 
that all cases had their first experience as mothers. 

Study Sample 

We selected at random 30 mothers and their infants: 
15 mother- infant couples exclusively under the 
breast-feeding mode from birth and 15 mother- 
infant couples exclusively under the bottle-feeding 
mode. The mothers were recruited from two 
public hospitals in Hermosillo, Sonora, Mexico. 



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Mothers were from low-income families and did 
not have social security medical services. 

Table I . Characteristics of Participants* 













Bottle- 




Breast- 


Characteristics 


feeding 


feeding 
Mothers 


of Mothers 


Mothers 








Mean age 


20.1 ± 2.1 


20.3 ± 2.6 


Mean years of 
education 


9.2 ± 2.2 


10.0 + 2.2 


Monthly family 
income (% 
minimum wage) 


1.9 ± 0.5 


1.5 ± 0.4 


Extended family 


75% 


84% 


Married 


68% 


92% 














Groun of 


Group of 
Infants 






Characteristics 
of Infants 


Infants 


Breast-fed 


Bottle-fed 


Mean birth 
weight (kgs) 


3.203 ± 
431.5 


3.161 ± 
301.5 


Length (cm) 


49.62 ± 2.1 


49.65 ± 
2.01 



*Mean, standard deviation, or percentage 

Study Design 

The study was descriptive and longitudinal, with a 
follow-up at 7, 45, and 60 days after birth 

Procedure 

We invited members to participate during their 
postpartum stays at the hospitals and obtained their 
informed consent. Later, we visited their homes at 
7, 45, and 60 days after delivery, and they were 
videotaped in different daily activities with their 
children, including the feeding periods. We first 
observed the videos to make a description of the 
mothers' and children's behavior during feeding. 
We then identified and defined the most frequent 
responses. In a second observation, we registered 
the response frequency within every 15-second 
interval of observation. An independent observer 
also registered the responses to calculate the 
reliability. Responses were grouped into four 
behavior categories— physical contact, verbal 



communication, visual contact, and other 
movements. 

Data Analysis 

A three-column form was designed to identify 
mother's and infant's behavior for each video. 
Behaviors were defined, coded, and classified. 
Frequency was recorded for every classification. 
Chi-square was used to analyze mother's and 
infant's behavior. 

Results and Discussion 

Results show that in some observed variables the 
mother practicing the breast-feeding mode was 
statistically associated with a high mother-infant 
interaction. The more significant behaviors were 
physical contact and verbal communication.' 
Mothers who breast-fed touched different body 
areas of their children more often and made vocal 
sounds during the lactation period (Tables 2 and 3). 

Table 2. Physical Contacts for Two Feeding 
Modes 





1 


Toucbmg 


Feeding 


' Mode 


Mother 
touches 


Breast (%) 


Bottle (%) 


Infant's head 


*37.5 


5.7 


Infant's face 


**45.8 


22.8 


Infant's arms 


27 


20 


Infant's hands 


33.3 


31.4 


Infant's legs 


20.8 


20 


Infant's feet 


4.1 





Infant's stomach 


4.1 





Infant touches 


Mother's hand 


27 


14.2 



♦Statistically significant (p<0.01) 
♦♦Statistically significant (p<0.05) 



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Table 3. Verbal Behavior for Two Feeding 
Modes 



Touching 


Feedin 


5 Mode 


Mother 


Breast (%) 


Bottle (%) 


Speaks to 
infant 


27 


40 


Sings to 
infant 


2.08 





Makes vocal 
sounds 


*12.5 











Infant 




Babbles 


45.8 


37 


Makes vocal 
sounds 


14.5 


14.1 


Cries 


6.2 


14.1 



* Statistically significant (p<0.08) 



In addition, we observed that breast-feeding mothers 
more quickly reacted to their infant's behavior 
changes than mothers in the bottle-feeding mode. 
However, we could not register the time between 
infant's response and mother's response, because it 
was of milliseconds. Therefore, we could not 
statistically analyze the mother's reaction time. 

We also think that the videocamera might restrict 
this study because it could inhibit spontaneous 
behavior. This could explain the low frequency of 
verbal behavior in the bottle-feeding mode. 

We conclude that it is possible to identify behavior 
differences between the breast-feeding and bottle- 
feeding modes. Additional information about other 
infant feeding situations will be useful to understand 
mother-infant interaction and the feeding mode. 
Including other responses different from touching 
and verbal sound would be of interest. 



Ainsworth MD. Some Contemporary Patterns of 
Mother-Infant Interactions in the Feeding Situation. 
Simulation of Early Infancy . London: Academic Press, 
1986. 

Arrieta R, Cravioto J. Maternal lactation: critical 
analysis . Mexico: National System for the Integral 
Development of the Family, 1985;46-82. 

De Araujo PV, Coutinho M, Falcao E, Macedo DM. The 
growth of babies fed exclusively with breast miUc 



during the first six months of life. Bol. ofSanit. Panam . 
1991;110:4(311-8). 

Temboury MC, Otero A, Polanco I, Arribas E. Influence 
of breast-feeding on the infant's intellectual development. 
Journal of Pediatric Gastroenterologv and Nutrition . 
1994; 18(32-6). 



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MODERN CONTRACEPTIVE 

TECHNOLOGIES AND 

ATTRIBUTES: PREFERENCES 

OF WOMEN ALONG 

THE U^.-MEXICO 

BORDER REGION 

Sandra Guzman Garcia 

Doctoral Candidate 

Federacion IVIexicana de Asociaciones 

Privadas de Desarrollo Comunitario 

Rachel C. Snow 

Ian W. Aitken 

Instructors 

Harvard School of Public Health 

Department of Population and 

International Health Research Affiliate 

ABSTRACT 

The purpose of this study was to document the 
perceptions and preferences of poor women hving 
along the U.S. -Mexico border region regarding 
modem contraceptive technologies. Our objective 
was to identify contraceptive attributes that women 
most like and dislike, the reasons for these 
preferences, and the strategies women employ to 
cope with contraceptive side effects and 
complications. 

Ten focus group discussions were held among 
married or cohabiting low-income women of 
reproductive age residing in 10 periurban colonias 
in Ciudad Juarez, Mexico. Method effectiveness 
was found to be the most important attribute in 
determining contraceptive preference. Also 
important was that the method allow women to 
maintain normal menstrual cycles as a reassurance 
that they were not pregnant. The majority of 
women did not express a need or interest in 
methods that allowed them to hide contraception 
from partners and/or family members. These 
preferences have important implications for the 
acceptability of specific contraceptive methods by 
women in the Ciudad Juarez region. 



Introduction 

Mexico's Population Policy and Family Planning 
Programs — Context 

In 1973, the Mexican government reversed its 
pronatalist population policy. The new policy 
sought to drastically reduce annual population 
growth rates. In the past 20 years, Mexico's total 
fertility rate has decreased by approximately 46%, 
from 5.7 births per woman in 1975 to the currently 
estimated rate of 3.1. This reduction is often 
credited to the pervasive activities of both 
governmental and private family planning 
organizations. Currently in Mexico, an estimated 
56% of married or "in-union" women of 
reproductive age are using a modem contraceptive 
method. At the international level, Mexico's family 
planning programs have been recognized as among 
the most successful in the world. Indeed, these 
programs should be credited for providing a much- 
needed service to Mexican women and couples. 

From Demographic Targets to Women's Priorities 

But in recent years, a global movement calling for 
a change in the traditional role of family planning 
programs has emerged. As determined at last year's 
International Conference on Population and 
Development, these programs are now being called 
upon to offer quality reproductive health services, 
with client priorities and satisfaction as their main 
focus. Key ingredients for ensuring program quality 
include providing a range of contraceptive choices 
and making efforts to meet client needs. 

Providing quality services also means understanding 
what factors make some contraceptives acceptable 
and others unacceptable. Most early studies 
examined reasons only for individual method 
discontinuation. These studies emphasize the 
negative impact of unpleasant side effects, therefore 
failing to generate a balanced view of what women 
actually like or want from a contraceptive and the 
fradeoffs they are prepared to make between a 
method's perceived advantages and disadvantages. 
And very few of these studies have included poor 
women, especially those living in developing 
countries. 

Purpose 

This paper discusses the findings of a Mexican case 
study designed to document women's preferences 



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for specific attributes of various contraceptive 
technologies. 

Background to Multisite Study 

This study is one part of a larger multisite study, led 
by a team of coinvestigators at the Harvard School 
of Public Health. These studies used focus group 
discussions among more than 600 women in cities 
in Cambodia, India, Mexico, Pakistan, Peru, South 
Africa, and the United States. 

Case Study: Ciudad Juarez. Chihuahua. Mexico 

The Mexican case study was conducted in Ciudad 
Juarez, Chihuahua, a border city separated from El 
Paso, its sister city, by a stretch of the Rio Grande. 
This border region is particularly known for its 
active maquiladora (assembly plant) industry, its 
heavily traveled international bridges, its poor 
environmental conditions, and the general relative 
poverty of its inhabitants. 

Methods 

Subject Recruitment 

For the purposes of the multisite study, we were 
looking for poor women of reproductive age (15- 
49), residing in urban or periurban neighborhoods, 
who were married or cohabiting, and who had some 
experience with modem contraceptive methods. In 
this case study, conducted during July and August 
of 1994, 10 focus group discussions were held with 
women residing in 10 corresponding poor urban 
neighborhoods or colonias. These women were a 
targeted convenience sample, identified and 
recruited by female community health promoters, 
or promotoras, residing in the respective colonias. 
The focus group discussions were hosted in the 
home of the coordinating promotora for each 
particular colonia. All the promotoras were 
affiliated with the Federacion Mexicana de 
Asociaciones Privadas de Desarrollo Comunitario, 
A.C. (FEMAP), a Mexican health and community 
development nongovernmental organization that 
has its national headquarters in Ciudad Juarez. This 
research effort would have been a very difficult 
undertaking without FEMAP 's generous assistance. 

It should be noted that this is a qualitative study and 
is not population-based. We do not make any claim 
that these results are representative of the larger 
population of women in Ciudad Juarez. 
Nevertheless, it was apparent from moderating the 



discussions that several dominant themes emerged 
that warrant further exploration in a larger 
representative sample. 

Focus Group Discussions 

All focus groups were conducted in Spanish and 
moderated by this country's investigator. After an 
introduction, basic information on each participant's 
personal characteristics was obtained using a brief 
questiotmaire. In the course of the focus group 
discussions, women were asked about a variety of 
contraceptive methods. The first part of each 
session focused on their personal familiarity and 
experiences with contraceptive use and their reasons 
for specific likes, dislikes, and preferences. In the 
second part, they were asked to discuss the. 
characteristics of an ideal method. And in the last 
section of the discussion, they were introduced to 
methods they had described as "unknown" or 
unfamiliar in Part I. In this latter section, women 
were provided with a hands-on display and verbal 
description of these methods, namely the 
diaphragm, the female condom, and spermicide 
preparations. 

Preparation of Transcripts 

Transcripts of each session were generated using 
videotapes of the sessions in addition to notes taken 
by an assistant who was native to the local region. 
After translation to English, these transcripts were 
independently verified for accuracy of translation 
before analysis. A total of 87 women from 10 
neighboring colonias ultimately participated in this 
study. The 10 colonias selected had been identified 
by FEMAP officials as locals believed to represent 
generally poor, urban communities. Although an 
attempt was made to recruit women of reproductive 
age, any woman who showed up to the discussion 
was welcome to participate. For this reason, the 
ages of the women ranged fi^om 15 to 78 years. 

The size of the focus groups varied from 6 to 13 
participants. The average participant was married, 
34 years of age, and had 3 living children. The 
educational experience of the women was highly 
varied, but 42% had completed a sixth-grade level 
of education; thus, 58% of all women had 
completed less than 6 years of primary education 
(see Table 1). 



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Participants' Familiarity and Experience with 
Contraceptives 

Table 2 shows the different methods that were 
discussed in the sessions. It also provides a sense 
of how many women in all 10 focus groups 
considered methods to be "known" or familiar, as 
well as an assessment of the number of women who 
stated that they had direct experience using those 
methods. 

The methods that women were most familiar with 
tended to be those with which women had the most 
direct experience, or which the women identified as 
"most commonly used in the community." These 
methods include oral contraceptive pills, the 
intrauterine device (lUD), the once-a-month 
injection, male condoms, and female sterilization, 
usually bilateral tubal occlusion. Many women had 
heard of Norplant, the 5 -year implant, but only a 
few knew of the diaphragm and female condom. 
Information about Norplant, the diaphragm, and the 
female condom was predominantly derived from 
television, magazines, and/or educational 
presentations given by the community promotoras. 
None of the women had any personal experience 
with these methods. With respect to most known or 
experienced methods, the women generally 
displayed little technical knowledge. A few women 
had heard of natural methods such as rhythm or 
withdrawal, vaginal suppository tablets (called 
"ovulos"), and contraceptive foam, but even fewer 
had actually tried these methods. None of the 
women claimed to have heard of contraceptive 
films and creams, and only one woman said she had 
heard of the sponge. Again, none of these women 
had ever tried these methods. 

Women's Preferences for Contraceptive Attributes 

In the analysis of the transcripts, the following four 

major themes emerged: 

^ Method effectiveness 

>" The tolerance of bleeding disturbances 

>- Reactions to barrier methods 

>" The importance of secrecy 

Method Effectiveness Importance 

Contraceptive effectiveness emerged as the most 
important attribute of a contraceptive regardless of 
whether the women were discussing familiar 
methods, ideal methods, or methods that were 
unknown. The hormonal contraceptives were 



thought to be the best fi-om this point of view, while 
the female barrier methods were thought to be the 
worst. The pill, one of the most commonly used 
methods, was felt to be the most effective method. 
In fact, most women preferred to use this method in 
spite of the need for daily attention. However, 
many women, extrapolating fi-om the experience of 
taking a daily pill, perceived it as a method that 
provides daily rather than monthly contraceptive 
protection. The value of diligently completing an 
entire pill pack to maximize effectiveness appeared 
to be underappreciated in these communities. 
An example of the importance of contraceptive 
effectiveness was seen in the discussion of the 
variety of unfamiliar female barrier methods. The 
women's interest fell rapidly upon being told that 
they were not completely reliable. Even the 
discussion of the diaphragm, sponge, and 
spermicides lost momentum when the women 
realized how relatively ineffective they were at 
preventing pregnancy. As one woman noted, "But 
that's the whole point; we need something 
effective." Barrier methods, quite apart fi"om other 
good or bad points, seemed not to be worth the 
effort to try because as many women noted, their 
effectiveness could "not be trusted." 

The lUD was the subject of conflicting attitudes 
regarding effectiveness. Some women felt that the 
lUD was a very effective method and considered 
themselves quite safe fi-om the threat of pregnancy. 
Other women discussed their experiences with the 
lUD falling out, breaking or rusting, and causing 
severe pain. Still others expressed their fears about 
stories of fiiends becoming pregnant while using the 
lUD. 

The Assurance of Effectiveness 

The importance of a method's effectiveness is also 
clear in the women's reactions to any bleeding 
irregularities. "Seeing a period" as assurance of 
effectiveness was very important to these women. 
In fact, most did not feel confident that they were 
not pregnant unless they experienced regular 
menstrual periods. For example, while most women 
acknowledged that longer-term injections, such as 
the 2- and 3 -month formulations, are quite effective, 
the experience of amenorrhea often caused them to 
change to methods that allow regular menstrual 
periods. For this reason, most women preferred a 



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1 -month injection over a 2-, 3-, or hypothetical 
6-month injection. However, while no woman had 
personal experience with Norplant, it was 
nevertheless perceived by many to be sufficiently 
effective. When told about the possibility of 
periodic amenorrhea associated with Norplant's 
use, most women stated that they would not 
consider missed periods as a substantial cause for 
alarm. 

With respect to the male condom, the concern about 
its effectiveness focused upon the reliability of the 
man using them, rather than any inherent deficiency 
in the condoms themselves. 

Duration of Method Effectiveness 

Other things being equal, long-acting 
contraceptives were considered better than short- 
acting ones. The idea of 5 years' protection by 
Norplant was met with enthusiasm, and monthly 
injections were considered more convenient than 
pills because they did not require daily attention. 
Norplant's long-term effectiveness was regarded as 
a good mechanism for spacing the birth of children, 
and it was seen as particularly good for older 
women who wanted long-term protection without 
the finality of sterilization. Interestingly, the lUD 
was mentioned only once in this context, and that 
was to commend its long-term protection compared 
with pills. 

Reversibility 

Interest in the length of effectiveness is qualified by 
a concern about the ability to reverse contraceptive 
effects when desired. The lUD and Norplant were 
considered more acceptable for that reason than the 
3 -month or proposed 6-month injection. The main 
problem with injections is the potential side effects. 
The women understood that longer-acting injections 
mean stronger doses of the drug, and therefore a 
greater probability of side effects, which they 
would have to endure for the duration. For women 
concerned about side effects, the inconvenience of 
the pill is preferable to the inability to discontinue 
a long-term injection once it has been administered. 

Tolerance of Bleeding Disturbances 

It was observed that, in these groups of women the 
amount and timing of menstrual bleeding seemed to 
be of universal and significant importance. 
Bleeding disturbances were referred to as "the worst 



types of problems," and several women had lUDs 
removed or stopped using injections for that reason. 
There appeared to be some women, however, who 
were prepared to trade off a certain amount of heavy 
or irregular bleeding for the convenience and 
confidence of a long-term method such as the lUD 
or Norplant. 

Some of the women who ultimately discontinued 
pill use due to bleeding problems stated that had 
they been better informed about what tj^jes of 
problems to expect, they might have tolerated this 
method a little longer. As noted earlier, the 
importance of "seeing a period" was repeatedly 
mentioned by different groups as the assurance of 
not being pregnant. The pill and the once-a-month • 
injection were often praised for this reason. One 
woman, in describing her anxiety over missing a 
period, said, "I would go crazy wondering if I was 
pregnant or not." Yet another said, "I needed to 
have a pregnancy test every month!" 

Reactions to Female Barrier Methods 

Overall, the most negative responses were reserved 
for the female barrier methods, even though these 
women had little knowledge and virtually no 
experience with these methods. Most women did 
not consider female barrier methods effective. In 
addition, all of the barriers displayed and discussed 
were considered the most inconvenient because of 
the difficulties of insertion and removal. These 
women also felt that it was bothersome to dispose of 
female condoms and sponges, as well as to clean 
and store diaphragms. Additional concerns about 
the diaphragm included the need to have it fitted by 
a health practitioner, the need to place it correctly in 
the vagina, whether it would stay in place, and 
whether it could be felt by a partner. 

Given all of the barriers' shared inconveniences, 
spermicide foam tablets and films seemed to be the 
least troublesome fi-om this perspective. Most 
women, nevertheless, found these methods 
unpleasant. And in three groups, women 
spontaneously expressed their dislike of having to 
touch themselves to insert or remove the 
contraceptive. 

Although all of the female barriers could be inserted 
prior to the sexual encounter, most women did not 
like that these methods could still potentially 



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interrupt intimacy. In this community, it appeared 
that the timing of intercourse is difficuh to 
anticipate and that the men cannot be rehed upon to 
be patient while a woman prepares herself. While 
the women appreciated the potential health benefits 
afforded by some of these methods, the 
inconveniences and the relative lack of 
contraceptive effectiveness prevented most women 
from wanting to try them. 

Male Condom 

There appeared to have been little experience with 
male condoms in most groups. This was primarily 
attributed to their male partners' reluctance to use 
them. However, in one group, a promotora did 
mention that 5 of her 30 clients used them and that 
her daughter distributed them in the community. 

Women appreciated that male condoms do not have 
the side effects that many other contraceptives have 
and that they offer protection from certain 
infections. Nevertheless, most women who had 
used them with their partners voiced the opinion 
that the condoms felt and smelled "sfrange" and 
"uimatural." Only a few women claimed that the 
physical sensation of intercourse was the same with 
or without the condom. Some women were 
concerned about the interruption of the act of 
intercourse and the possibility of the man losing his 
erection. There were a few women who reported 
that their husbands did use condoms regularly, and 
these women, in their own words, were very happy 
that their husbands "took care of them." 

The overwhelming consensus was that men simply 
did not like to use condoms. Most men apparently 
complained about the loss of sensation, saying, "It's 
like sucking on a candy with the wrapper still on." 
The women believed that their partners understood 
the protective effect of condoms against diseases, 
but they were quick to point out that understanding 
this advantage did not increase a man's desire to 
use condoms. However, several women and a 
couple of the promotoras speculated that while men 
would not use condoms with their wives, they 
would probably use them with other women. 

Other Male Methods 

Discussion of other male methods arose in half of 
the groups, usually in the context of ideal methods. 
Several women felt that it would be ideal for them 



if their partner agreed to obtain a vasectomy. But 
they were also quick to note that this situation was 
highly unrealistic as most men in their community 
view a vasectomy as a threat to their masculinity. In 
many of the discussions about male methods, 
women often came to the conclusion that greater 
educational efforts were needed to make vasectomy 
and condom use more acceptable to the men. 

In four of the groups, women wondered why 
scientists were not developing any new 
contraceptives for men. There seemed to be 
agreement that any male contraceptive would need 
to be easy to use because, in their opinion, "the men 
are so difficult to convince." The women felt that it 
would be best if the new method were a pill or 
injection that could be used periodically and would 
offer long-term protection. 

The Importance of Secrecy 

The need for secrecy in a confraceptive method 
arose spontaneously in 4 of the 10 groups. In most 
cases, women spoke abstractly about how "some 
women" would benefit from this attribute if their 
partners were the type who did not permit them to 
use contraception. Only three women explicitly 
stated that their husbands did not allow them to use 
any method. "Machismo," it was alleged, led some 
men to be opposed to any form of contraception, but 
in their own words, this was not nearly as common 
as in earlier years. 

In the situations where a woman's partner forbade 
her to use contraception, it was acknowledged that 
women would have no choice but to take the 
contraceptives secretly. Generally, there did not 
seem to be any difficulty in "fooling" partners, 
because many men did not understand about the 
different methods of contraception. Women felt 
that methods like the pill or the injection would be 
easiest to use without their partner's knowledge. In 
the majority of groups, the general consensus was 
that there was no need for secrecy in a method 
because men "nowadays" were much more 
supportive of women. Some men, they claimed, 
even purchased contraceptives for them. 

It was clear from these discussions that the majority 
of women felt themselves to be the ultimate 
decision makers regarding how and when to use 
contraception. But it was also apparent, by the way 



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in which women continuously referred to their 
partners in a variety of contexts, that the male 
opinion was not something to be taken lightly. 

Conclusion 

In conclusion, it is worth noting again that the 
results of this qualitative study are not generalizable 
to the larger population of women in Ciudad Juarez. 
The value of a study such as this, in which women 
are provided with an opportunity to engage in a 
structured, yet free-flowing, discussion around a 
set of issues, is that we gain some insight into how 
women perceive and respond to these issues. 
Overall, three significant messages emerged from 
the Ciudad Juarez case study. 

First, contraceptive effectiveness is of overriding 
importance in a preferred method. This importance, 
however, is qualified somewhat by the fear of 
unpleasant side effects. 

Second, there is a significant desire for women to 
experience regular menstrual periods. Even when 
the symptom of amenorrhea is expected or known 
to be a normal side effect of a method, women still 
long to see monthly periods with a sense of 
urgency. 

Third, female barriers are virtually unacceptable 
due to the perception of many negative attributes. 
The women do appreciate that these methods do not 
cause systemic side effects, and that they offer 
some protection from sexually transmitted diseases. 
But even so, the opposition to the female barriers is 
so multifaceted that it will indeed be a challenge to 



determine how these methods could become more 
acceptable to women such as these. 

Words of Wisdom 

The conclusions drawn from this study are as yet 
preliminary and tentative, as they are part of a more 
substantive process of data collection, including 
population-based approaches such as random 
household surveys. Nevertheless, the Ciudad Juarez 
case study demonsfrates that it is indeed feasible to 
use qualitative field approaches to collect data on 
the subject of women's preferences for 
contraceptive attributes. It also shows that there are 
creative ways to talk to poor women about these 
preferences and that more than likely the women 
will have strong opinions on some issues. 

What are the most suitable contraceptives to meet 
the needs of poor women in places such as the urban 
colonias of Ciudad Juarez? What is the best mix of 
currently available confraceptives, and what 
attributes are important to new methods that need 
to be developed? Where are the voices of poor 
women in this decision making process? 

These are the types of questions that inspired us 
when we set out to design and conduct the multisite 
studies. It was our collective hope that we could 
contribute in a small way to the international effort 
to improve the quality of reproductive health 
services for women, especially poor women, around 
the world. 



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Table 1 . Description and Composition of 1 
Focus Groups Conducted in Urban Colonias of 
CiUDAD Juarez, Chihuahua, Mexico 



Focus 

Group 

Colonia 


Mean 

Age 
(+ 1 SD) 


Mean# 
of Living 
Children 


Formal 
Education 
%>6 
years 




Azteca 


32 


2.1 


14 


Division del Norte 


34 


2.3 


29 


Melchor Ocampo 


36 


2.3 


83 


Tierra Libertad 


27 


2.5 


45 


Insurgentes 


33 


3.0 


27 


Francisco Madero 


37 


3.1 


30 


Leyes de Reforma 


33 


3.2 


31 


Mirador 


34 


3.3 


57 


La Cuesta 


34 


3.4 


71 


IndependenciaSl 


44 


4.3 


33 


Totals 


34 (+ 12.4) 


2.9 


42 



Table 2. A Qualitative Assessment of 
Knowledge and Use of a Variety of 
Contraceptive Methods as Indicated by Women 
Participating in Focus Group Discussions Held 
IN Ciudad Juarez, Chihuahua, Mexico 



Contraceptive 
Method 


Knowledge of 
Method 


'' 'VseW''' ^^ 
Method 


Hormonal Methods 






Oral Contraceptive Pill 
(OCP) 


MOST 


MOST 


Injection 


MOST 


MANY 


Norplant 


MANY 


NONE 


Intrauterine Device 


MOST 


MANY 


Barrier Methods 






Male Condom 


MOST 


FEW 


Female Condom/Diaphragm 


FEW 


NONE 


Sponge and Fihn 


ONE 


NONE 


Spermicide Preparations 






Vaginal Cream, Foam, 
Suppository Tablet 


FEW 


FEW 


Sterilization Procedures 






Tubal Ligation and 
Hysterectomy 


MOST 


FEW 


Vasectomy 


MOST 


ONE 


Natural Methods 






Rhythm and withdrawal 


FEW 


FEW 



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BELIEFS OF THE PREGNANT 

WOMAN ASSOCIATED WITH 

PRENATAL CARE 

CREENCIAS DE LA MUJER 

EMBARAZADA ASOCIADAS 

CON EL CUIDADO PRENATAL 

Ana Laura Quintero Crispin, 

Licensed Nurse 

Dr. Charlotte Rappsilber 

Universidad Autonoma de Nuevo Leon 

IVIonterrey Nuevo, Leon, IVIexico 

ABSTRACT 

Proposal 

To determine what beliefs of pregnant women 
contribute to the decision for prenatal care. 

Methodology 

The design was descriptive, retrospective, and 
transversal. The study group consisted of pregnant 
women belonging to the municipality of Apodaca, 
Nuevo Leon. Two hundred thirty-five blocks of the 
lower socioeconomic class in this city were visited, 
and a probability sample was obtained of 240 
pregnant women between the ages of 24 and 44 
with below-average education. Using a Likert-type 
scale of 4 points, a Scale of Beliefs About Prenatal 
Care (SBPC) consisting of 28 items and 
sociodemographic data was administered to these 
women. The SBPC was developed based on the 
Rosenstock Model of Health Beliefs (1988). The 
analysis of the data was done using the "SPSS/PC" 
to obtain descriptive statistics, chi-square, V of 
Cramer, and the Coefficient of Correlation of 
Pearson, with a level of significance of 0.05. 

Results 

Sixty percent of the pregnant women were less than 
24 years old, 54% reported having an education 
below primary level, 90% were housewives, and 
80% had a partner. The same proportion of women 
who were having their first child went for care as 
those who already had children, and 48% were in 
the second trimester of pregnancy. Thirty-six 
percent did not have prenatal care, and 30% did not 



take care of themselves at home. Prenatal care was 
associated with susceptibility, severity, benefits, 
barriers, and signals for action, in a significant 
manner (p < 0.05) in moderate magnitude. 

Conclusions 

(1) The Model of Health Beliefs permitted the 
differentiation in the nature of prenatal care through 
the association of its constructs with this variable; 

(2) The instruction of prenatal care to pregnant 
women based on beliefs would favor a change in 
strategies of educational intervention with this 
population. 

NOMENCIATURA 

>- APS — Atencion Primaria de Salud 

^^ MCS — Modelo de Creencias de Salud 

> CPN — Control Prenatal 

> ECCP — Escala de Creencias sobre el Cuidado 
Prenatal 

>" N — Universo de Estudio 

5* n — Muestra 

>> p — Probabilidad 

> NS — Nivel de Significancia 

>* AGEB — Area Geoestadistica Basica 

> X^ — Chi-Cuadrada 

> r — Coeficiente de Correlacion de Pearson 
5=* V — Coeficiente de Correlacion de Cramer 

Resumen 

El proposito del presente estudio fue determinar 
cuales son las creencias de la mujer embarazada que 
contribuyen al cuidado prenatal. 

El diseiio fue descriptivo en su modalidad 
correlacional, retrospectivo y transversal. La 
poblacion de estudio estuvo conformada por las 
mujeres embarazadas pertenecientes al municipio de 
Apodaca, Nuevo Leon. La muestra fue 
probabilistica por conglomerados. Se visitaron 235 
manzanas del estrato socioeconomico bajo y se 
obtuvo una muestra de 230 mujeres embarazadas 
entre los 24 y 44 ailos de edad, con escolaridad 
inferior al nivel basico. Se les administro una Escala 
tipo Likert de 4 puntos denominada "Escala de 
Creencias sobre el Cuidado Prenatal (ECCP)", 
constituida por 28 items y datos sociodemograficos. 
La ECCP, se elaboro en base al Modelo de 
Creencias de Salud (MCS) de Rosenstock (1988). El 
analisis de los datos se hizo a traves del SPSS/PC, 
para obtener estadisticas descriptivas. 



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Chi-Cuadrada, V de Cramer y el coeficiente de 
Correlacion de Pearson, con un nivel de 
confiabilidad de .05. 

Entre los hallazgos mas relevantes estan que el 36 
por ciento de las embarazadas no acudio a su 
control prenatal, y el 30 por ciento no realize 
cuidados prenatales en el hogar. El cuidado prenatal 
se asocio de manera significativa con las" variables 
del MCS, susceptibilidad, severidad, beneficios, 
barreras y senales para la accion (p=<.05), en 
magnitud moderada. 

El MCS permitio relacionar las creencias de las 
embarazadas al cuidado prenatal a traves de sus 
unidades. La enfermera en salud comunitaria al 
considerar los resultados de este estudio podra 
fimdamentar estrategias educativas especificas para 
lograr un cambio de conducta y reforzar los 
conocimientos acertados que posee la embarazada 
sobre su cuidado en este periodo. 

CAPITULO 1 

INTRODUCCION 

En 1978, se celebro la Reunion de Alma Ata en la 
cual se establecio la estrategia de Atencion Primaria 
de Salud (APS) aplicable en todos los niveles de 
atencion. Dentro de los objetivos de APS, esta el 
atender a poblaciones vulnerables tales como ninos, 
ancianos, incapacitados, trabajadores y mujeres 
embarazadas. Para lograr esto, se requiere de la 
implementacion de programas en cada grupo de 
poblacion en donde el equipo multidisciplinario de 
salud tiene la responsabilidad includible de resolver 
dos problemas principales: 1) poner al alcance la 
atencion de salud y, 2) comprometer al individuo, 
familia y/o comunidad en la busqueda de su 
bienestar. 

Como ya se menciono, uno de los grupos 
vulnerables que requieren de mayor atencion es el 
de las mujeres embarazadas, poblacion de interes en 
esta investigacion, la cual se enfoco en las creencias 
asociadas con el cuidado prenatal. 

Es preciso hablar de la atencion prenatal, ya que 
representa una etapa dificil de sobrevivencia que 
requiere de un proceso integral de cuidado, 
caracterizado por la accesibilidad, universalidad, 
equidad, continuidad y satisfaccion de necesidades 
prioritarias (Bobadilla, 1988). 



Poma (1987), refiere que la mujer embarazada en 
muchas ocasiones fracasa al llevar su cuidado 
prenatal, situacion que aunque dificil, representa la 
oportunidad de la enfermera comunitaria para 
proporcionar educacion, prevencion y guia a esta 
poblacion, basandose en el entomo social en el cual 
se desenvuelve la embarazada y tratar de que 
considere esta etapa no como un cambio estresante, 
sino como un cambio positive que implica 
responsabilidad para su salud y la de su bebe. 

La mayoria de las investigaciones se han dirigido a 
las complicaciones y problemas que se presentan 
con mas frecuencia durante el periodo perinatal, 
pero pocos estudios abarcan los posibles factores 
relacionados con el cuidado prenatal. Por esta razon 
la presente investigacion se baso en el Modelo de 
Creencias de Salud (MCS). 

El MCS ha sido empleado para buscar predictores 
relacionados a la busqueda de cuidado prenatal, pero 
no se ha utilizado todo el modelo para establecer 
eslabones entre uno y otro de sus elementos. 

En un estudio reciente, Bluestein & Rutledge 
(1993), han propuesto un marco teorico basado en el 
MCS para investigar las determinantes psicosociales 
del cuidado prenatal temprano, en las embarazadas 
con desventajas socioculturales. Sin embargo, este 
marco es mas apropiado para estudios 
longitudinales que para los de corte transversal, 
como el que se presenta en este documento. 

El MCS proporciona un marco teorico de trabajo 
para describir las conductas de la mujer embarazada 
y apoyar el rol del educador y proveedor de cuidado, 
a los que relativamente se les da poca atencion en la 
literatura cientifica de enfermeria. 

Planteamiento Del Problema 

Dentro de la APS, existe un topico que se toma 
prioritario a nivel mundial, estatal y local, "la salud 
matema," la cual se ve afectada por las 
complicaciones relacionadas con el embarazo y 
durante el parto, favoreciendo el incremento en la 
morbimortalidad matemo-infantil. "Cada aiio a nivel 
mundial, se embarazan mas de 200 millones de 
mujeres, aproximadamente 130 millones dan a luz 
y cerca de 500 mil de estas fallecen a causa de 
complicaciones prevenibles" (Viegas, 1992). 



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Estudios en America Latina evidencian que a pesar 
de que algunos embarazos son de mayor riesgo que 
otros, se estima que por cada 100,000 nacidos 
vivos, mueren aproximadamente 300 mujeres en el 
transcurso de su embarazo (Rinehart, W., 1988). 
Por su parte, en Mexico las afecciones originadas 
en el periodo perinatal ocupan el sexto lugar entre 
las causas de muerte, con una tasa de 14.4 por 
100,000 habitantes. En el estado de Nuevo Leon 
ocuparon el mismo lugar, pero con una tasa de 19.4 
por 100,000 habitantes (Institute Nacional de 
Estadistica, Geografia e Informatica, INEGI, 1993). 

Mora & Yunes (1993), realizaron un estudio 
respecto a la mortalidad matema en America Latina 
y el Caribe, en el que reportaron para Mexico, una 
tasa de 82 por cada 100,000 nacidos vivos, con una 
evitabilidad de muerte estimada del 52 por ciento. 
En Mexico, entre las principales causas de muerte 
durante la gestacion estan: la toxemia, aborto, 
hemorragia, infecciones, anemia, problemas 
relacionados con la nutricion, que generalmente 
ocurren en la etapa de gestacion y en el 90 por 
ciento de los casos son prevenibles (Alarcon, 1993; 
Bobadilla, 1988; Moysen, & Ruiz, 1991; Rinehart, 
1988; Rodriguez, et al., 1991; Santos, et al., 1991). 

Tambien se han dirigido investigaciones en el 
estrato socioeconomico bajo, concemientes al 
cuidado prenatal y al uso de servicios de salud en 
este periodo. Entre los resultados mas relevantes, 
estan que mas del 30 por ciento de las embarazadas 
no acuden a la atencion prenatal y en muchos de los 
casos, las mujeres cuyos hijos han tenido bajo peso 
al nacer, nunca llevaron medidas preventivas 
durante el embarazo (Alcalay, Ghee, & Scrimshaw, 
1993; Moysen, & Ruiz, 1991; y Rodriguez, Angulo, 
Vargas, Martinez, & Corona, 1991). 

Posiblemente existen otras causas que influyen en 
la busqueda de atencion y toma de medidas 
preventivas, entre las que pudieran estar, las 
costumbres, tradiciones, percepcion de la atencion 
prenatal, informacion recibida o el sentirse bien 
(Viegas, 1992; Langer, Bobadilla, Bronfman, & 
Avila, 1988). Sin duda todo esto puede tener 
impacto en la salud matema e infantil, tomandose 
en un problema que atane a la Salud Publica donde 
esta inmersa la enfermera especialista en salud 



comunitaria a la que le corresponde valorar el 
impacto social y las repercusiones a corto plazo en 
el individuo, familia y/o comunidad. Los danos 
obstetricos y riesgos a la salud de la madre y el niiio 
pueden ser prevenidos, detectados y tratados a 
tiempo y con exito a traves de la intervencion 
fundamentada en la indagacion del conocimiento, 
percepcion y experiencia de la embarazada y en la 
identificacion de barreras que influyen para obtener 
el cuidado prenatal. 

Cabe destacar que algunas experiencias de 
enfermeras a nivel local, muestran que a pesar de 
los esfuerzos en la coordinacion e implementacion 
del Programa de Control Prenatal (CPN), mas del 50 
por ciento de las mujeres embarazadas acuden en el 
tercer trimestre solo para la programacion de su 
parto (IMSS, UMF No. 28, UMF No. 5, & Hospital 
de Gineco obstetricia No. 23, 1994). 

Por otra parte, en las unidades de primer nivel de 
atencion de la Secretaria Estatal de Salud y del 
Proyecto UNI (1994), las mujeres acuden en el 
primer trimestre de su embarazo, pero solo la 
minoria acude a las citas subsecuentes. A esto 
tambien hay que agregar que la participacion de la 
enfermera comunitaria es escasa. 

Lo expuesto en parrafos anteriores, refleja la 
complejidad de la conducta de la mujer para decidir 
participar en el cuidado prenatal y sobre todo 
porque parece existir responsabilidad compartida 
entre la institucion, proveedor de cuidados y 
paciente. 

Debido a que se requiere de informacion adicional 
de otros factores propios de la mujer que pudieran 
estar asociados con el cuidado prenatal, se propuso 
la siguiente investigacion basada en el MCS como 
sustento teorico que permite incorporar diversas 
variables y dar respuesta al siguiente 
cuestionamiento: 

^Cuales son las creencias de la mujer embarazada 
que se asocian con el cuidado prenatal? 

Hipdtesis 

Para esta investigacion se propusieron las siguientes 
hipotesis: 



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Hip6tesis 1 

> Hi = La Susceptibilidad y Severidad percibidas 
sobre el embarazo se asocian con el cuidado 
prenatal. 

^ Ho = La Susceptibilidad y Severidad percibidas 
sobre el embarazo no se asocian con el cuidado 
prenatal 

HlPOTESIS 2 

>■ Hi = Los Beneficios y Barreras que percibe la 

embarazada con respecto al CPN, se asocian con 

el cuidado durante este periodo. 

> Ho = Los Beneficios y Barreras que percibe la 
embarazada con respecto al CPN, no se asocian 
con el cuidado durante este periodo. 

HlPOTESIS 3 

>■ Hi = Las Seiiales para la accion que tiene la 

embarazada se asocian con el cuidado prenatal. 
>* Ho = Las Sefiales para la accion que tiene la 

embarazada no se asocian con el cuidado 

prenatal. 

Objetivos 

> Objetivo General 

• Determinar cuales son las creencias de la 
mujer embarazada que contribuyen a la 
decision del cuidado prenatal. 

5=* Objetivos Especificos: 

• Identificar la Susceptibilidad y Severidad que 
la mujer percibe con respecto al cuidado 
prenatal. 

• Indagar los factores modificantes que pueden 
influir en el cuidado prenatal de la 
embarazada. 

• Identificar los beneficios y barreras que 
percibe la embarazada para obtener el cuidado 
prenatal. 

>* Importancia Del Estudio 

• La importancia de esta investigacion para la 
enfermeria con especialidad en salud 
comunitaria radica en que en la actualidad las 
relaciones de la comunidad con los servicios 
de salud se ban incrementado (Milio, 1992) lo 
cual exige la realizacion de estudios que guien 
la toma de decisiones respecto a los 
programas de salud existentes y la educacion; 
para apoyar e informar, en este caso a las 
embarazadas, sobre su responsabilidad en 
materia de salud. 

• La implicacion de los resultados de esta 
investigacion en la practica de enfermeria es 
apoyar la implementacion de programas 
educativos por parte de la enfermera 



comunitaria encaminados a modificar, en la 
medida que sea posible, aquellas conductas 
nocivas para la mujer durante el embarazo 
dada la magnitud, no solo a nivel local, de la 
mortalidad matema como un indicador de la 
desventaja de salud en que se encuentra esta 
poblacion. 

• Porter, (1989) asevera que las enfermeras 
comunitarias tienen la habilidad principal para 
la enseiianza del cuidado de salud y que 
pueden ayudar a la paciente embarazada a 
tomar su responsabilidad tanto para su salud, 
como para el bienestar de su bebe. 

• Ademas, este estudio pone en evidencia la 
importancia del uso de elementos teoricos, en 
este caso el MCS, que pueden dirigir mejor las 
intervenciones en la poblacion de 
embarazadas, al explicar la participacion de las 
mismas en el programa de control prenatal. 

> Limitaciones Del Estudio 

• Las limitaciones fueron de orden 
metodologico: 

♦ Los resultados del estudio solo se pueden 
generalizar para aquellas poblaciones de 
embarazadas de estrato socioeconomico 
bajo, con caracteristicas similares a las 
encontradas en la muestra del Municipio 
de Apodaca, N.L. 

♦ Al momento de recolectar la informacion 
y localizar a los sujetos de estudio en las 
manzanas seleccionadas al azar (n=235), 
hubo manzanas en donde no se 
encontraron mujeres embarazadas y 
debido a que el tiempo para recoleccion 
de datos no fue suficiente (3 meses) no se 
sustituyeron por otras. 

♦ La Escala de Creencias sobre el Cuidado 
Prenatal (ECCP), disenada por el autor 
para la recoleccion de datos, tuvo un alfa 
de 0.7433, considerando como aceptable 
su consistencia intema total. Sin embargo, 
las escalas que la forman tuvieron 
variabilidad en la consistencia intema, por 
lo que esto representa ima limitante del 
estudio. 

Definici6n De Tdrminos 

>> Mujer Embarazada 

• Es aquella mujer que se encuentra en un 
estado fisiologico que inicia con la 
fecundacion y dura 9 meses, hasta el 
nacimiento del producto a termino (Diario 
Oficial de la Federacion, 1993). 



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>* Control Prenatal 

• Es la vigilancia y monitoreo de la mujer 
embarazada enfocada a detectar y prevenir 
riesgos de la madre y del nino. Las siguientes 
definiciones se basaron en los elementos 
teoricos del Modelo de Creencias de Salud de 
Rosenstock, (1977 y 1988): 

>* Susceptibilidad Percibida 

• Es cuando la mujer embarazada cree de si 
misma que tendra un embarazo normal o de 
riesgo. 

♦ Baja: < lOpuntos 

♦ Moderada: 11-15 puntos 

♦ Alta: 16- 20 puntos 
5^ Severidad Percibida 

• Es cuando la mujer embarazada anticipa 
consecuencias negativas que se podrian 
presentar en el embarazo. 

♦ Baja: < 10 puntos 

♦ Moderada: 11-16 pimtos 

♦ Alta: 17-24 puntos 
>* Beneficios Percibidos 

• Es cuando la mujer embarazada cree que el 
tener cuidado prenatal reduce los riesgos 
durante el embarazo. 

♦ Bajos: < 10 pimtos 

♦ Moderados: 11-13 puntos 

♦ Altos: 14-16 puntos 
^^ Barreras Percibidas 

• Es cuando la mujer embarazada cree que el 
cuidado prenatal es inaccesible o 
inconveniente debido al costo, horario, 
localizacion, vergiienza, o experiencia. 

♦ Baj as: < lOpuntos 

♦ Moderadas: 11 - 19 puntos 

♦ Altas: 20 - 28 puntos 
>- Senales para la Accion 

• Personas o medios de comunicacion que la 
mujer embarazada cree que le brindan 
informacion sobre el cuidado prenatal para 
acudir a su control. 

♦ Bajas: < 10 puntos 

♦ Moderadas: 11 - 16 puntos 

♦ Altas: 17 a 24 puntos 
>■ Factores Modificadores 

• Son aquellos atributos de la mujer embarazada 
que pueden modificar el curso de la decision 
de Uevar el cuidado prenatal (Edad, 
escolaridad, religion, ocupacion, estado civil, 
servicios de salud). 



> Cuidado Prenatal 

• Son aquellas medidas que la mujer cree que 
evitaran que su embarazo sea riesgoso: acudir 
al control prenatal, cuidados realizados en este 
periodo (ejercicio, citas, alimentacion, vestido, 
descanso, entre otros). 

>* Estrato Socioeconomico Bajo 

• Clasificacion de las areas municipales que se 
realiza en base a dos indicadores, uno 
representa las caracteristicas de construccion 
de la vivienda y el otro el recibir de ingreso 
economico im salario minimo o menor por 
semana (INEGI, 1993). 

^^ Embarazo de alto riesgo 

• Se considera mujer embarazada de alto riesgo 
aquella que tiene el previo conocimiento de 
estar desarroUando alguna enfermedad o 
complicacion diagnosticada (toxemia, anemia 
severa, gestacion multiple, entre otros 
factores) (Organizacion Panamericana de 
Salud, OPS, 1986). 

CAPITULO 2 

Marco Teorico 

El estado de salud durante toda la vida de la mujer 
se ve afectado por los riesgos que enfrenta en el 
embarazo y en el parto. A nivel mundial se estima 
que muere una mujer cada minuto como resultado 
de estos periodos. En America Latina el numero de 
defunciones rebasa los 300 por 100,000 bebes 
nacidos vivos, lo que representa un indicador de la 
necesidad de realizar esfuerzos constantes para 
mejorar el estado de salud de este grupo poblacional 
(Rinehart, 1988). 

Por otra parte, Mora & Yune (1993), seiialan que en 
su mayoria las defunciones matemas son evitables, 
ademas argumentan que se pueden mejorar las 
condiciones educativas y de salud de la mujer y 
quiza de esta manera se podria influir mas sobre los 
resultados del embarazo. La evitabilidad se puede 
lograr a traves del mejoramiento de la calidad de la 
atencion medica y de la accesibilidad geografica a 
los servicios de salud, la dotacion de transporte 
adecuado y oportuno y de la disminucion de los 
efectos de las variables sociales, culturales y 
economicas adversas. Es a partir de este momento 
en que se debe realizar una valoracion del entomo 
en el que vive esta poblacion y considerar los 
estudios que ban reportado que la atencion prenatal 



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se asocia fuertemente con los resultados del 
embarazo y que de el depende la buena salud de la 
madre y del nino (Rodriguez, McFariane, Mahon, & 
Fehir, 1994; Alcalay & Cols., 1993). 

La atencion del embarazo empieza en la 
comunidad, en el lugar donde vive la gente, 
utilizando los recursos existentes, inte^ando la 
atencion de salud tradicional con los servicios de 
atencion mas modemos. La comunidad es el lugar 
ideal para que la mujer reciba atencion basica, de 
forma sencilla y sin requerir de equipos 
sofisticados. 

Monteith (1987), seiiala que al estudiar la 
utilizacion de los servicios de salud por parte de las 
mujeres embarazadas, debe considerarse la 
tendencia de que "las mujeres mas instruidas y en 
posicion economica mas desahogada utilicen mas 
los servicios de salud que se prestan en areas 
urbanas, y recientemente hay una mayor 
accesibilidad para aquellas poblaciones dispersas o 
muy alejadas, favoreciendo el incremento en el uso 
del cuidado prenatal. 

En el ailo de 1993, se expidio con caracter de 
emergencia la Norma Oficial Mexicana 
NOM-EM-002-SSA2, para contribuir a la 
disminucion de la morbilidad y mortalidad matema 
atribuible en un 80 por ciento a las complicaciones 
durante el embarazo normando la orientacion 
adecuada sobre los cuidados prenatales y los signos 
de alarma y corresponsabilizar a la mujer de su 
propia salud y la de su nino. Dirige el CPN hacia la 
deteccion y control de los factores de riesgo 
obstetrico, a la prevencion, deteccion y tratamiento 
de afecciones indirectas como anemia severa, 
toxemia, infecciones, complicaciones hemorragicas, 
retraso en el crecimiento intrauterino. En esta 
norma se establecieron las siguientes actividades a 
realizar durante el control prenatal: 

>- Elaboracion de historia clinica, 

>" Medicion y registro de peso, talla y presion 

arterial, 
>* Valoracion del crecimiento intrauterino y estado 

de salud del feto, 
>" Realizacion de examenes de laboratorio y de 

gabinete, 
>* Aplicacion del toxoide tetanico, prescripcion 

profilactica de hierro y acido folico, 



>- Orientacion nutricional, 

>" Identificacion de signos de alarma, 

>" Autocuidado de la salud, y 

>> Minimo de 5 consultas prenatales. 

El Plan Nacional de Desarrollo 1995-2000 en 
materia de salud, seiiala que en nuestro pais 
coexisten muertes matemas y perinatales que 
afectan sobre todo a los grupos de menores ingresos, 
relacionados con los estilos de vida que se traducen 
en una mayor frecuencia de enfermedades que 
seran tratadas a traves del mejoramiento de la 
calidad de los servicios que se prestan y la extension 
de cobertura (Diario Oficial de la Federacion, 1995). 
Por su parte, el subprograma matemo-infantil, se 
orienta a proteger la salud tanto de la mujer durante 
el embarazo, parto y puerperio, como la del niiio 
desde su etapa intrauterina hasta los cinco anos de 
edad. 

Lo anterior denota que el uso del cuidado prenatal 
es una prioridad a nivel nacional, sin embargo, no se 
han disminuido las tasas de mortalidad matemo- 
infantil (E^GI, 1993), por lo que se debe intentar 
llevar a la mujer al sistema de cuidado de salud en 
etapas tempranas de su embarazo. Se requiere de 
trabajo en equipo, de intercoordinacion, de la 
accesibilidad de los servicios, de unificacion en la 
comunicacion, de la modificacion de actitudes, 
conductas profesionales y poblacionales, pero sobre 
todo de la integracion de las pacientes en forma 
directa al cuidado prenatal. 

No se trata de responsabilizar solo a la mujer y mas 
cuando no posee una cultura de salud, carece de 
accesibilidad o escasos recursos economicos, sino 
de incorporar todos aquellos factores que influyen 
en la decision de la misma para tomar o no la accion 
preventiva, y junto con el profesional de enfermeria 
en salud comunitaria, se busquen las mejores 
altemativas para responder a las barreras o factores 
no financieros, maximizando los recursos de la 
misma mujer (experiencia, conocimiento) y los 
existentes en los centros de salud de cada 
comunidad. 

El Modelo de Creenoas de Salud (MCS) y el 
Cuidado Prenatal 

Para el presente estudio se eligio uno de los modelos 
mas antiguos, desarrollado en la decada de los 
cincuentas por Hochbaum y asociados de los 



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servicios de Salud Publica de los Estados Unidos, 
denominado "Modelo de Creencias de Salud," 

para explicar el por que y bajo que condiciones la 
gente toma las acciones preventivas (Rosenstock, 
1974). 

En el desarrollo inicial del modelo de Hochbaum 
(1958) se incluyeron cuatro variables: 
susceptibilidad, severidad, barreras y beneficios 
percibidos. Posteriormente en los 70's Becker y 
Rosenstock, (1974) introdujeron la motivacion y 
Pender (1982) propuso incluir las variables control 
percibido y valor de la salud. La ultima revision del 
MCSftieenl988. 

El MCS, esta compuesto de tres grandes unidades 
que a su vez se componen de diversas variables: 
(a) Percepcion Individual, (b) Factores 
Modificadores, y (c) Probabilidad de Accion, los 
que se ilustran en el siguiente esquema: 

EsQUEMA No. 1 Modelo De Creencias De Salud, 
Becker, Et Al, 1974) 

PERCEPCKi^INDrvnXJAL + FACrcRESMXIinCADCRES= HCBABDEAOaciM 



SUBCEFTIBILIDAD PEROBIDA A 
"X" ENFERMEDAD 



^VEREWD PEROBinA DE LA 
ENFERMEDAD'V 



DATOS DEMOGRAnOOS 
EnAaSE>aiRAZA 

ESIRUCRRALES 
CCNOOMIENTO Y EXreREvOA 

soaopsiaxdacAS 

PERSCNALIDAQ OASE SOCIAL, 
ETC 



BENEnaOS FEBOEnXB Y 
AOICNES PREVENTIVAS 



BARRERAS fERflBIDAS: 



AMENAZA PEROBIDA 



SENALESDEAOaON 

CAMPANAS 

ASESCRiADEOIRCS 

REOCKDATCRIOS 

ENFERMEDAD DE IN FAMEJAR 

ARTICLLCS DE FERK±XGOS / 

REVISTAS 



En los ultimos anos los profesionales de enfermeria 
han utilizado ampliamente el MCS para examinar 
las conductas preventivas en la poblacion con 
diabetes mellitus, infarto de miocardio, cancer, 
inmunodeficiencia adquirida, enfermedades 
sexualmente transmisibles, enfermedades 
ocupacionales asi como en la alimentacion, 
realizacion de la autoexploracion mamaria, en el 
tabaquismo, alcoholismo y en la experiencia 
comunitaria de los estudiantes de enfermeria 
(CINHAL, 1994). 

En el estado de Nuevo Leon a traves de la Facultad 



de Enfermeria, U.A.N.L, el MCS se ha aplicado en 
investigaciones dirigidas a las medidas preventivas 
en la displasia cervical, planificacion familiar, y en 
el abandono y falta de control del tratamiento de la 
tuberculosis (Compendio de Tesis, 1994). 

Respecto a su aplicacion en el cuidado prenatal, solo 
se han aplicado algunas variables del modelo, para 
iniciar el diseiio de escalas que midan las creencias 
prenatales (Wells, Mcdiarmid & Bayatpour, 1990); 
las actitudes e intenciones hacia el embarazo 
(Tiedje, Kingry, & Stommel, 1992) o acerca de la 
efectividad del programa prenatal (Clarke & Cols., 
1993). No obstante, estos investigadores han 
sugerido que se realice un mayor esfuerzo cientifico 
para aplicar este modelo teorico al cuidado prenatal. 

Especificamente, Bluestein & Rutledge (1993), han 
propuesto el MCS para investigar las determinantes 
psicosociales del cuidado prenatal tardio entre las 
mujeres en desventaja economica. Consideran que 
el uso de este modelo puede proporcionar el 
entendimiento de aquellos atributos psicosociales 
que son esenciales para mejorar el proceso y 
resultados del cuidado prenatal. 

Para la enfermeria comunitaria, el MCS, es una 
herramienta de aproximacion al entendimiento de la 
conducta relacionada con la salud (Mikhail, 1981). 
Ademas, proporciona la libertad de elegir la 
estrategia de intervencion pertinente ya sea para un 
individuo o para un grupo de personas, en una 
situacion especifica. Incrementa la percepcion 
realista de los beneficios de una accion de salud, y 
asi el profesional de enfermeria puede hacer 
importantes contribuciones al desarrollo del modelo, 
y relacionarlo con los modelos propios de 
enfermeria. Es importante reconocer que el MCS 
requiere de mayor refinamiento en la relacion de sus 
unidades y en su aplicabilidad a diversos grupos de 
poblacion. Mullen, Hersey, & Iverson, (1990) en un 
estudio comparativo de tres modelos de conductas 
de salud, entre ellos el MCS, refieren que este 
modelo tiene variables altamente predictivas de la 
conducta de salud, pero que su parsimonia, 
especificidad y aceptabilidad deben mejorarse a 
traves de la investigacion. En los siguientes parrafos 
se amplian las unidades del modelo, en base a 
estudios que sin aplicar la totalidad de las variables 



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del mismo, reconocen la utilidad para explicar la 
conducta de salud de la embarazada. 

Percepci6n Individual 

Se refiere a las creencias que facilitan la conducta 

de salud y se dividen en: 

>- Susceptibilidad Percibida a la enfermedad, 

condicion de salud o problema si no se toma una 

accion preventiva. 
> Severidad Percibida, grado en que la persona cree 

que puede adquirir alguna condicion de salud 

negativa o tener algiin riesgo para su salud 

(Rosenstock, 1974, 1988) 

Al respecto, Mullen, Hersey, & Iverson, (1990) en 
su revision del MCS, refieren que la susceptibilidad 
depende mucho de lo que la persona conozca acerca 
de la salud y enfermedad, y la severidad depende 
del conocimiento que tienen las personas sobre los 
riesgos para la salud si se tiene alguna conducta 
negativa hacia la misma. 

Bluestein & Rutledge (1993), en su propuesta que 
hicieron de la aplicacion del MCS con respecto al 
cuidado prenatal, suponen que cuando la 
susceptibilidad y la severidad son bajas hay un 
retraso en el cuidado prenatal. Agregan que la 
susceptibilidad percibida baja puede impedir el 
reconocer y confirmar que se esta embarazada. Por 
otra parte, la severidad percibida baja puede retrasar 
la busqueda de las citas de contiol asi como la 
identificacion de los signos de alarma. 

En 1992, Tiedje & Cols., iniciaron el desarroUo de 
un cuestionario para medir las conductas de salud 
durante el embarazo, tales como el alcoholismo, 
tabaquismo y nutricion. Entre sus resultados 
encontraron que tanto la susceptibilidad como la 
severidad fueron fueites predictores de la conducta 
de la embarazada para no optar por conductas 
nocivas hacia su salud (p<.001). 

Factores Modificadores 

En esta unidad se incluyen variables de tipo 
demografico, sociopsicologico y estructurales, que 
a lo largo de la historia del modelo han sido 
fuertemente criticadas debido a que aun no se 
conoce con claridad la relacion que guardan con la 
conducta de salud. 

Bluestein & Rutledge (1993), proponen que para el 
estudio de las creencias de la mujer embarazada, 
entre los modificadores sociodemograficos que 



deben incluirse estan la edad, raza, estado civil, 
paridad, ingreso, educacion y conocimiento 
relacionado con la salud. En los psicosociales se 
encuentran, autoestima, eventos de la vida, salud 
subjetiva, apoyo social. En los estructurales estan 
la disponibilidad, accesibilidad, y necesidad de 
acomodarse en el cuidado. 

Respecto a la multiparidad, Alcalay (1993) encontro 
diferencias significativas entre las primiparas y 
multiparas en relacion a la busqueda de informacion 
sobre el control prenatal y en el seguimiento de 
recomendaciones dadas por los profesionales de 
salud (p<.001). Joyce, Diffenbacher, Greene & 
Sorokin (1983), en un estudio realizado en 
Cleveland, encontraron que la edad es un factor 
importante tanto para la busqueda de la atencion 
durante este periodo como para las altemativas de 
solucion a las barreras que interfieren en la 
recepcion del cuidado. 

Rodriguez & Cols. (1991), a pesar de que no se 
basaron en el MCS, encontraron relacion entre la 
mortalidad matema y el cuidado prenatal con la 
edad de las mujeres, acudiendo mas aquellas que 
tuvieron edades que oscilaron entre los 35 y 39 
aiios. 

En 1988, en Portugal se llevo a cabo un estudio de 
salud matema para buscar las causas que originan la 
morbimortalidad durante el embarazo asi como para 
el no acudir al control prenatal. Los hallazgos 
evidenciaron que el cuidado prenatal no esta 
asociado con el estrato social, educacion u 
ocupacion de la embarazada (p>.05). 

Dentro de esta unidad tambien se encuentra la 
variable denominada senal para la accion, 
relacionada con todas aquellas fuentes de 
informacion que pueden influir en el individuo 
como "una serial de alerta" y entonces decidir seguir 
o no la accion de salud. 

Al respecto algunos investigadores coinciden en que 
el cuidado prenatal puede ser motivado por los 
medios de comunicacion, familiares, amistades, por 
la pareja, pero en especial por la madre. Alcalay 
(1993), en un estudio de intervencion educativa en 
las embarazadas concluye que los medios de 
comunicacion (radio, television, posters, foUetos, 
entre otros) son motivadores importantes para el 



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seguimiento del cuidado prenatal. Aaronson (1989), 
en una investigacion enfocada al apoyo percibido y 
recibido durante el embarazo hacia el consume de 
alcohol, tabaco o cafeina, reporto que el apoyo 
recibido de la familia, pareja, amistades, se asocia 
mas a tales conductas (p<.001). 

Probabilidad de Acci6n 

Se refiere a la direccion que va a tomar la accion 
influenciada por las creencias beneficas hacia 
diferentes altemativas de salud. El individuo, en 
este caso la mujer embarazada, percibe los 
beneficios, pero tambien identifica cuando un 
beneficio se toma en barrera, por su inaccesibilidad, 
costo, tiempo, inconveniencia y localizacion. 

Bluestein & Rutledge (1993) refieren que los 
beneficios percibidos por la mujer embarazada van 
encaminados a la preservacion de la salud fetal y 
matema, a la reduccion del estres, a recibir apoyo y 
a los beneficios de tener acceso a los servicios de 
salud. De esta manera los beneficios pueden estar 
determinados por las acciones personales, la ayuda 
de los profesionales de salud, y por el 
asesoramiento recibido. Inversamente una mujer 
embarazada percibe poco beneficio cuando tiene 
experiencias negativas, o cuando cree que el 
cuidado prenatal no afectara los resultados del 
embarazo. Los beneficios percibidos bajos pueden 
estar asociados con el ingreso, la falta de educacion, 
y la falta de conocimiento o de valor de las acciones 
preventivas, tales como el cuidado prenatal. 

Por su parte las barreras constituyen una parte 
negativa hacia el embarazo, cuidado prenatal o 
hacia los proveedores del cuidado. Generalmente 
las adolescentes embarazadas, multiparas y madres 
solteras reflejan conviccion de que el cuidado 
prenatal y que la distancia cultural enti-e ellas y el 
proveedor de cuidado son barreras amplias. Sin 
embargo, como seiialan los investigadores, y 
muchos otros colegas, las embarazadas que refieren 
barreras para el cuidado son altamente vulnerables 



psicosocialmente y por eso tienen estas actitudes 
negativas. Tiedje & Cols. (1992) no encontraron 
relacion entre los beneficios/ barreras y los cuidados 
prenatales con respecto al tabaquismo, alcoholismo 
y nutricion (p>001). Stone (1993) realize un estudio 
para determinar las barreras para llevar un 
inadecuado control prenatal, para esto controlo la 
variable financiera, y a pesar de ello, reporto que las 
barreras tienen sus origenes en la pobreza y son: 
madre soltera, con menos educacion, multiparas, sin 
transporte propio, uso de drogas, y ambivalencia 
hacia el cuidado prenatal. 

Por otra parte, Joyce & Cois (1983) y York, 
Williams, & Hazard (1993), condujeron sus 
investigaciones hacia la biisqueda de las barreras 
intemas, extemas para obtener el cuidado prenatal, 
en ambos estudios se controlo el estado financiero 
y el transporte. Entre los hallazgos mas destacados 
estan: la falta de seguro de salud, de apoyo familiar, 
de cuidado de sus demas hijos, ambiente clinico, 
embarazo no planeado y depresion. En ambos 
estudios se concluyo que las barreras tienen relacion 
con aspectos personales de la embarazada. 

En otras investigaciones, las barreras mas fi^ecuentes 
para no acudir al control prenatal fiieron el acceso al 
servicio, costo y distancia del servicio de salud, 
atencion recibida, "nervios" al acudir a un centro de 
salud y el transporte. (Rodriguez, et al., 1994; 
Alcalay &Cols., 1993; Potter, 1988). 

Finalmente, la estrategia de la presente 
investigacion es medir en lo posible cada una de las 
variables del MCS para determinar cuales son las 
creencias que dirigen o guian a la embarazada a su 
cuidado prenatal. Para lo cual se adapto el modelo 
al cuidado prenatal. 

En el Esquema No.2, se presentan los indicadores 
propuestos para medir cada una de las unidades: 



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ESQUEMA NO.2 MODELO DE CREENCIAS DE SALUD Y 

EL CuiDADO Prenatal 



percepc[6n individual 



FACTORES MODIFICADORES 



PROBAB. DE ACCI6N 



SUSCEPTIBILIDAD 
Y SEVERIDAD 
PERCIBIDAS 
HACIA 
ELEMBARA20 



DATOS DEMOGRAFICOS (EDAD. 
ESCOLARIDAD. ESTADO CIVIL, 
OCUPACI6N) 

PSICOSOCIALES (RELIGI6N. 
SERVICIOS DE SALUD, ESTRATO 
BAJO) 

ESTRUCTURALES (PARIDAD, MESES 
DE EMBARAZO, CPN) 



BENEnCIOS PERCIBIDOS 
(DE RECIBIR INFORMACI(!)N, 
CHARLAS. HABITOS) 

BARRERAS PERCIBIDAS 
(CCSTOS, HORARIOS, 
DISTANCIA, VERGOENZA, 
EXPERIENCIA) 



/ 



SEl^AL PARA LA ACCI6N 
(CONSEJO DE PAREJA, PERSONAL 
DE ENFERMERlA, FAMILIA, MEDIOS 
DECOMUNICACI6N) 



PROBABILIDAD DE MAS 
CUIDADO PRENATAL ACUDIR 
A CPN, REALIZARCUIDADOS 
DURANTE EL EMBARAZO) 



CAPITULO 3 

Metodologia 

Diseflo de la Investigaci6n 

La investigacion fue de tipo descriptiva en su 
modalidad correlacional, retrospectiva y transversal 
(Polit, 1994). 

Sujetos 

La poblacion estuvo conformada por el total de 
mujeres embarazadas pertenecientes al Municipio 
de Apodaca, N.L. La muestra se determino a traves 
de una estimacion de proporciones debido a la 
caracteristica particular de la poblacion estudiada. 
Primero se obtuvo el total de manzanas de estrato 
socioeconomico bajo del municipio arriba 
mencionado N=600, con la finalidad de obtener una 
muestra probabilistica por conglomerados, dando un 
total de n=235 manzanas a visitar. Los criterios para 
la seleccion de los sujetos de estudio fueron: 

>> Criterios de Inclusion: 

• Mujer embarazada, que sepa leer y escribir y 
que resida en las manzanas seleccionadas del 
municipio de Apodaca, N.L. 

>* Criterios de Exclusion: 

• Mujer embarazada, que no sepa leer y escribir, 
que no se localice en las manzanas de la 
muestra o que refiriera tener diagnosticado un 
embarazo de alto riesgo. 

Material 

Para el logro de los objetivos de la investigacion, se 
diseiio una escala tipo Likert de 4 puntos 
denominada "Escala de Creencias sobre el Cuidado 
Prenatal" (ECCP). Compuesta de cinco subescalas 



en base al Modelo de Creencias de Salud (MCS) de 

la siguiente manera: 

>' Subescala susceptibilidad percibida= 5 items = 20 

puntos 
>' Subescala severidad percibida= 6 items = 24 

puntos 
>* Subescala beneficios percibidos= 4 items = 16 

puntos 
>" Subescala barreras percibidas= 7 items = 28 

pimtos 
>" Subescala senales para la acci6n= 6 items = 24 

puntos. 
> Total de puntos: = 28 items = 112 pimtos 

Las opciones de respuesta fueron: 

>" Totahnente de acuerdo (4 puntos) 

>" De acuerdo (3 puntos) 

>^ En desacuerdo (2 puntos) 

>- Totalmente en desacuerdo (1 punto) 

En la primera parte del instrument© se recolectaron 
los datos demograficos y cuidados prenatales (Ver 
APENDICE A). Para el instrument© se diseno un 
instmctivo de codificacion y programa de captura 
(Ver APENDICE B) 

Procedimientos 

Antes de colectar la informacion se realize una 
prueba piloto con 15 embarazadas con 
caracteristicas similares a las de la muestra. Se 
hicieron modificaciones a algunos items de la 
escala, asi como tambien se categorizaron las 
preguntas semiabiertas. 

Se contrataron 3 encuestadores, y se les proporciono 
un entrenamiento sobre el contenido del 
instrument©, su aplicacion y c©dificaci6n, asi c©m© 
la localizacion de las Manzanas seleccionadas en el 
Municipio de Ap©daca, N.L. a traves de l©s mapas 
p©r Ageb del mism© municipi© adquiridos en el 
ESTEGI (Ver APENDICE C). Tambien se solicito 
autorizacion a la Jurisdiccion N©. 4 para la 
aplicacion del instrument© en el lugar citad©. 

El levantamient© de dat©s se llevo a cab© del mes de 
febrer© al mes de abril del presente ail©. El 
procedimient© especific© para la aplicacion del 
instrument© consistio en l©s siguientes pas©s: 
>* Localizacion de cada una de las manzanas. 
>» Una vez localizada la manzana en la colonia 
correspondiente, se hizo un recorrido por la 
misma para identificar a aquellas mujeres 
embarazadas. 



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>" Cuando se selecciono a una embarazada como 
parte de la muestra se procedio a explicarle el 
objetivo del estudio por medio de un documento 
por escrito, acerca del cual se hablara mas 
adelante. Tambien se les pregunto si estaban 
recibiendo algun tratamiento o si padecian alguna 
enfermedad o en su defecto una complicacion y si 
asi fue, se les explico el por que no podrian 
participar en el estudio. Cabe destacar que 
solamente 1 1 embarazadas estuvieron en esta 
situacion. 

> Si las embarazadas reunian los criterios de 
inclusion se administraba el instrumento, el cual 
tuvo un tiempo promedio de aplicacion de 1 5 
minutos. 

La codificacion y captura de datos fue semanal, se 
proceso por medio electronico utilizando el 
Statistical Package for the Social Science (SPSSPC) 
(Paquete Estadistico para las Ciencias Sociales) 
para aplicar la estadistica descriptiva (frecuencias, 
porcentajes, media, y desviacion estandar) asi como 
la prueba de Chi-Cuadrada (X^) y la prueba V de 
Cramer para las hipotesis y el coeficiente de 
correlacion de Pearson (r), para las variables del 
MCS, con un nivel de confiabilidad de .05 y un 
error estimado de .06. 

El tiempo destinado para el proceso formal de esta 
investigacion fue desde el mes de Agosto de 1994 a 
Mayo de 1995. 

Etica del Estudio 

Por las caracteristicas del estudio y el tipo de 
instrumento aplicado, se consideraron los siguientes 
aspectos eticos: 

> Estudio de riesgo minimo, conforme al 
Reglamento de la Ley General de Salud en 
Materia de Investigacion, Art. 17 cap. 11 (1987). 

>' Se solicito a cada una de las participantes su 
consentimiento informado por escrito, segiin el 
Capitulo I, Art. 13 fraccion V. (Ver APENDICE 
D) 

>- Se dio oportunidad y garantia de dar respuesta a 
cualquier pregunta y aclaracion, una vez 
concluido el Estudio. 

>* Se considero la libertad de retirar su 

consentimiento en cualquier momento y dejar de 
participar en el estudio, asi como la de mantener 
la identidad en el anonimato para proteccion de la 
privacidad. Art. 21, Fracciones VI, VII y VIII y 
Art. 22 fraccion I. 



CAPITULO 4 

Resultados 

Los resultados del presente estudio se han 
subdividido en tres partes. La primera respecto a las 
caracteristicas sociodemograficas relacionadas con 
el cuidado prenatal (Control Prenatal [CPN] y 
cuidados durante el embarazo). La segunda en 
relacion con la comprobacion de las Hipotesis de 
investigacion y la tercera a la correlacion de las 
variables del Modelo de Creencias de Salud (MCS). 

Caracteristicas Sociodemograficas v el Cuidado 
Prenatal 

Para esta parte se aplico la estadistica descriptiva y 

la no parametrica (Chi-Cuadrada X^ y V'Cramer) 

para dar mayor significancia estadistica a estos 

hallazgos. 

La variable dependiente de este estudio se dividio 
en dos indicadores, Acudir a CPN y los Cuidados 
Realizados durante el Embarazo. Respecto al 
primer indicador se encontro que el 36 por ciento 
(82) refirio no acudir a CPN y para el segundo 
indicador se encontro que el 30 por ciento (140) no 
realize cuidados prenatales en su hogar. Los 
hallazgos anteriores se ilustran en la Figura 1 : 

FiGURA 1 . Cuidado Prenatal De La Pobiacion 
EstudiadaApodaca, N.L, 1995. 



n=230 






SI 


NO 


CPN 
CUIDADOS 


<4 
70 


36 
30 



Fncntc: Aplicaclin de EscaU de Creencias de Cuidado Preaatal (ECCP), 1995 

Un aspecto importante que se encontro, fue que a 
mas del 3 1 por ciento (72) de las embarazadas les 
preocupa el momento del parto y al 24 por ciento 
(57) no le preocupo nada. 



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Los indicadores de la variable dependiente se 
relacionaron con las caracteristicas 

sociodemograficas, encontrando que en relacion a la 
edad el 60 por ciento (139) tuvo una edad menor a 
los 24 anos. Cabe destacar que de los que no 
acudieron al CPN, el 23 por ciento (53) estuvieron 
en este rango de edad. 

Respecto a la escolaridad, el 54 por ciento (124) 
refirio haber cursado estudios inferiores al nivel 
basico. Sin embargo, un porcentaje casi similar de 
embarazadas segun la escolaridad no acudieron al 
CPN, 20 (45) y 16 por ciento (38) respectivamente. 

En cuanto a la ocupacion, el 90 por ciento (207) 
fueron amas de casa y el 32 por ciento de ellas (73) 
no acudio a CPN. 

El 80 por ciento (184) de las embarazadas que 
refirieron tener pareja, acudieron mas al CPN que 
las que refirieron no tener pareja. 

Al aplicar la X^ para conocer la asociacion de estas 
variables se encontro que solo el estado civil se 
asocio con el CPN, con una significancia de p<.001 
y una V de Cramer que indica una magnitud de 
relacion moderada de 0.36419. Los resultados 
anteriores se presentan en la siguiente Tabla: 



Tabla J . Caracteristicas Sociodemograficas De 
Las Embarazadas Relacionadas Con El Cpn 



Apodaca, N.L., ] 


995 


n = 230 














Caracteris- 
ticas 


Si 
CPN 


No 




Signiti- 
cancia 


CPN 






Total 


x^ 








EDAD 










< = 24 a. 


37% 


23% 


60% 


NS 


>24a. 


27% 


13% 


40% 




ESCOLARIDAD 










< Primaria 


34% 


20% 


54% 


NS 


> Primaria 


30% 


16% 


46% 




OCUPACION 










Ama de casa 


58% 


32% 


90% 


NS 


Trabaja 


6% 


4% 


10% 




ESTADO 










Con pareja 


54% 


26% 


80% 


p<.0001 


Sin pareja 


10% 


10% 


20% 





Fuente: Aplicacion de ECCP, 1995 NS = No Significativo 

En lo correspondiente a la religion se obtuvo que el 
20 por ciento (49) de las que manifestaron no llevar 
CPN no profesaron alguna religion. 

El 44 por ciento (101) no pertenecia a algiin servicio 
de salud y de estas el 30 por ciento (71) se ubicaron 
en las que no acudieron a CPN. 

En cuanto a Multiparidad y Trimestre de embarazo, 
el 50 por ciento (115) fueron primigestas y 
el 48 por ciento (109) estuvieron en el segundo 
trimestre de embarazo. 

Al aplicar la X^ a estas variables solo se encontro 
asociacion entre la religion y el CPN con una 
significancia estadistica de p<.01 y una V de 
Cramer de 0.3 159 es decir una magnitud de relacion 
moderada como se ilustra en la continuacion de la 
Tabla 1: 



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CONTiNUACiON Tabla 1 . Caracteristicas Sooodemograficas Relacionadas Con El Cpn 

Apodaca. N.I.. 1995 n = 230 



Fuente: Aplicacidn de ECCP, 1995 

El segimdo indicador del cuidado prenatal, los 
cuidados realizados durante el embarazo, se asocio 
de manera significativa con la escolaridad (p <.05, 
0.2204), encontrando que el 34 por ciento (79) de 
las embarazadas que tuvieron estudios menores a 



Cara«t?ri$ti?»$ 


SfCPN 


No CPN 


Total 


N.S. x' 


RELIGION 








P<.01 


Si 


48% 


16% 


64% 




No 


16% 


20% 


46% 




TIPO SERV DE SALUD 








p<.0001 


Ninguno 


14% 


30% 


44% 




IMSS 


32% 


5% 


37% 




SSA 


13% 


1% 


14% 




DIP 


3% 




3% 




Privado 


2% 




2% 




PARIDAD 








NS* 


Primipara 


31% 


19% 


50% 




Multipara 


33% 


17% 


50% 




MES EMB. 








NS 


ler. trim. 


16% 


9% 


25% 




2do. trim. 


27% 


21% 


48% 




3er. trim. 


21% 


6% 


27% 





la primaria realizaron algun cuidado y de las que 
refirieron tener escolaridad por arriba de este nivel 
buscaron mas las recomendaciones del personal de 
salud, como se muestra en la siguiente Tabla: 



Tabla 2. Caracteristicas Sooodemograficas Relacionadas Con El Cuidado Durante El Embarazo 

n=230 



Caracteristicas 


Cuid 
Gral 


Rec 


Rec 


Rec 


Nada 


No 
Cont 


Total 


Significaxicia 


Enf 


Med 


Fam 


ESCOLARIDAD 
















P<.05 


< Prim. 


34% 


1% 


2% 


1% 


8% 


6% 


52% 




< Prim. 


27% 


3% 


1% 


2% 


8% 


7% 


48% 




ESTADO CIVIL 
















P<.01 


C/pareja 


50% 


2% 


3% 


1% 


13% 


11% 


80% 




S/pareja 


11% 


2% 




1% 


3% 


3% 


20% 




Fuente: Aplicaci6n de 


ECCP, 199 


5 















En la Tabla anterior, tambien se puede observar que 
otro dato demografico que se relaciono con los 
cuidados fue el estado civil con una p<.01, y una V 
de Cramer de 0.19224, lo que puede indicar que las 
embarazadas que refirieron tener pareja realizaron 
algun cuidado prenatal, representadas por el 50 por 



ciento (115) del total. 

El resto de las variables sociodemograficas no se 
asociaron a los cuidados durante el embarazo. Como 
ya se menciono en capitulos anteriores, las variables 
del MCS, se dividieron en niveles bajos, moderados 



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y altos de acuerdo al puntaje obtenido en las 
subescalas correspondientes. Es asi como para la 
susceptibilidad percibida el 73 por ciento (168) de 
las embarazadas tuvieron nivel moderado (Ver la 
Figura 2). En este nivel, 92 embarazadas se 
percibieron susceptibles a la salud de su bebe y a los 
efectos que pudiera ocasionar el tabaco o el alcohol. 

Figura 2. Niveles De Susceptibilidad YSeveridad 
Percibida RespectoAl Cuidado Prenatal De Las 
Embarazadas 

Apodaca. N.L.. 1995 




■ SUSQFIIBILIDAD 
D aVEnOAD 



suscEPTmninAD 

SEVERIDAD 


15 
4 


73 
55 


12 
41 



Fuente: Aplicacibn de BXP, 1995 

Para la severidad percibida un 55 por ciento de las 
embarazadas (126) estuvo en nivel moderado y un 
41 por ciento en un nivel alto (Ver la Figura 
anterior). Al respecto 69 de estas embarazadas 
percibieron la severidad hacia el aborto y a las 
alteraciones del crecimiento del bebe. 

Respecto a los beneficios percibidos, el 49 por 
ciento (112) de las embarazadas estuvieron en el 
nivel bajo (Ver Figura 3). Cabe destacar que 92 de 
ellas no percibieron los beneficios de la informacion 
proporcionada en los servicios de salud, asi como la 
importancia de las platicas que brindan las 
enfermeras para el cambio de algunos habitos 
nocivos en este periodo. 



Figura 3. Niveles De Beneficios Y Barreras 
RespectoAl Cuidado Prenatal De Las 
Embarazadas 

Apodaca. N.L.. 1995 



n=230 



f M 




1 




I 






N 








^^ 


'm 


LpI 


-M 



I BENEFICIOS 
I BARRERAS 



MODERADO 



BENEFICIOS 
BARRERAS 


49 

7 


44 
78 


7 
15 



Fuente: Aplicacion de ECCP, 1995 

En relacion a las barreras percibidas, tambien se 
puede observar que el 78 por ciento (179) estuvo en 
el nivel moderado. Dentro de las barreras que mas 
se percibieron estan los costos, horario de consulta 
y el transporte, referidas por 69 de las participantes. 

En la variable Sefiales Para la Accion, el mayor 
porcentaje estuvo en el nivel alto con un 48 por 
ciento (111) (Ver Figura 4). Es importante seiialar 
que 81 embarazadas percibieron que su pareja le 
anima a acudir al CPN, 147 creen que la madre o la 
suegra le brindan consejos y cui dados en este 
periodo, y 150 creen que la informacion que brindan 
las enfermeras les podria ayudar durante su 
embarazo. 

Figura 4. Niveles De Sen ales Para La Accion 
Percibidas Por Las Embarazadas 

Apodaca. N.L.. 1995. 



n=230 




Fuente: Aplicaci6n de ECCP, 1995. 



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Cabe destacar que las embarazadas no perciben 
como un beneficio el acudir a las platicas educativas 
de enfermeria, mas bien las perciben como una 
opcion informativa de sefiales para la accion. 

Comprobacion de las Hip6tesis de Investigaci6n 
Como se cito en parrafos anteriores, para la 



comprobacion de las hipotesis se aplico la 
Chi-Cuadrada (X^) para conocer la dependencia 
entre las variables y la V de Cramer para determinar 
la magnitud de dicha relacion. En la Tabla 3 se 
muestran los resultados de la Hipotesis No. 1 . 



Tabla 3. Distribucion De Chi-cuadrada ()^) Para La Susceptibiudad Y Severidad PerobidaAsooadas 
Con El Cuidado Prenatal 

Apodaca. N.L.. 1995 



Percepcion 


g» 


X^ Tedrica 


X' Calculada 


p < .05 


V Cramer 


Susceptibilidad/CPN 


14 


23.6800 


17.9219 


0.2104 


0.2791 


Susceptibilidad/Cuidados 


14 


23.6800 


81.505 


0.0500 


0.3662 


Severidad/CPN 


13 


22.3600 


6.7719 


0,9135 


0.1715 


Severidad/Cuidados 


2 


21.0260 


83.1925 


0.0002 


0.4159 



Fuente: Analisis estadistico de la ECCP a traves del SPSS/PC, 1995 



Como se puede observar, el Control Prenatal no se 
asocio ni con la susceptibilidad ni con la severidad 
percibida (p >.05). Mientras que los Cuidados 
realizados durante el embarazo se asociaron 
significativamente (p<.05) y con un valor de 
Cramer V que indica relacion moderada (0.3662 y 
0.4159), aqui es importante senalar que la 
percepcion individual de la mujer embarazada 
puede determinar el hecho de que ella realice los 
cuidados durante este periodo. 

En la Tabla 4, se ilustran los datos del analisis 
estadistico de la Hipotesis No. 2 de esta 
investigacion. Los beneficios no se asociaron con 
acudir al CPN, (p>.05) pero si con los cuidados que 
la embarazada realiza durante este periodo (p<.05), 
lo cual muestra una relacion moderada de 0.3338. 



Tabla 4. Distribucion De X^ Para Las Barreras Y 
Beneficios Percibidos Asociados Con El 
Cuidado Prenatal 

Apodaca. N.I.. 1995 



Probab. 
Accion 


g 

1 


X^ 

Teorfca 


X^ 
Calculada 


P< 
.05 


V Cramer 


Beneficios/ 
CPN 


2 


5.991 


1.9961 


0.3886 


0.0931 


Beneficios/ 
Cuidados 


1 



18.307 


32.972 


0.005 


0.3338 


Barreras/ 
CPN 


2 


5.991 


0.80291 


0.6693 


0.0590 


Barreras/ 
Cuidados 


1 
2 


31.410 


83.1925 


0.0085 


0.3296 



Fuente: Analisis estadistico de la ECCP a traves del SPSS/PC, 1995 

For otra parte, las barreras tambien solo se asociaron 
con los cuidados (p<.0085) en un nivel de relacion 
moderado (0.3296). Es posible inferir que la 
decision de acudir a CPN, no necesariamente 
significa que la embarazada realizara los cuidados 
porque percibe beneficios, sino que los cuidados que 
realiza pueden depender de que tan beneficos u 
obstaculizantes sean dichos cuidados. 



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En la Hipotesis No. 3 se asociaron las variables 
Senales Para la Accion y el Cuidado Prenatal, 
encontrando una situacion estadistica similar a la de 
las hipotesis anteriores, es decir, el indicador 
cuidados realizados durante el embarazo se ve 
influenciado por las senales para la accion (p<.05), 
no asi el acudir a CPN. 

Cabe destacar que al confrontar las variables CPN 
y cuidados realizados, se asociaron 
significativamente p <.0010, en un nivel de relacion 
moderado (0.2990), con lo que se evidencia que las 
embarazadas que acuden a CPN son las que realizan 
mas de un cuidado, pero no por recomendacion del 
personal de salud. 

Correlaci6n de las Variables del Modelo de 
Creencias de Salud fMCS) 

Se aplico la correlacion de Pearson (r) para analizar 
las relaciones entre las variables del MCS y se 
constato que este modelo continua siendo 
multivariado. En la Tabla 5 se observan los 
resultados de la correlacion en donde la variable 
susceptibilidad se relaciono con la severidad, 



beneficios y seilales para la accion, mas no con las 
barreras. 

Por otro lado, la severidad percibida se relaciono 
con susceptibilidad, beneficios y seilales para la 
accion. Los beneficios se asociaron fuertemente con 
las seilales y esta ultima se asocio con todas las 
variables excepto con las barreras. Todo parece 
indicar que la variable Barreras Percibidas es 
independiente de las demas y que requiere de un 
mayor estudio o de la biisqueda de barreras 
personales de la embarazada y no del programa en 
si. 

A pesar de que no era la intencion validar el 
instrumento, se aplico una prueba de confiabilidad- 
de Cronbach para determinar la consistencia interna 
del mismo, encontrando que para los 28 items que 
constituyeron la Escala, el alfa fiie de 0.7433 con 
una significancia entre las mediciones de p<.0001. 
Es importante destacar que esta confiabilidad es una 
base para que en estudios fiituros se aplique este 
instrumento y se mida su consistencia interna. 



Tabla 5. Coefioente De Correlaci6n De Pearson (R)para Las Variables Del Mcs 

Apodaca. N.L.. 1995 



Variables 


Susceptibilidad 


Severidad 


Beneficios 


Barreras 


Sefiales 


Susceptibilidad 


1.0000 


0.46630*** 


0.26031*** 


0.4218 


0.35781*** 


Severidad 




1.0000 


0.33062*** 


0.0006 


0.33488*** 


Beneficios 






1.0000 


0.0580 


0.32995 


Barreras 








1.0000 


0.07383 


Senales 










1.0000 



Fuente: Analisis Estadistico a traves del SPSS/PC. p<.01*, p<.001**, p<.0001'' 



CAPITULO 5 

DiSCUSION 

Interpretaci6n 
En este estudio se establecieron tres hipotesis a 
partir de las unidades del Modelo de Creencias de 
Salud (MCS) y se asociaron con el cuidado prenatal 
(acudir a CPN y los cuidados realizados durante el 
embarazo). Como primer punto se encontro que la 
susceptibilidad y la severidad percibida se 
asociaron con el cuidado realizado durante el 
embarazo pero no con el acudir a CPN, hallazgo 
que apoya lo referido por Bluestein «fe Rutledge 
(1993) respecto a que el reconocimiento y retraso 



de la biisqueda del cuidado prenatal dependen del 
nivel de severidad y susceptibilidad que perciba la 
embarazada. 

Asi, en el presente estudio se encontro un nivel 
moderado tanto en susceptibilidad como en 
severidad, y el grupo de embarazadas en este nivel 
file el que manifesto Uevar a cabo algun cuidado 
durante su embarazo. Tambien concuerda con lo 
mostrado por Tiedje & Cols. (1992), que al medir 
susceptibilidad y severidad en la embarazada 
siempre habra una relacion entre estas variables, ya 
que parece que no hay una discriminacion mental 



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entre el ser vulnerable y el como le pueden afectar 
las consecuencias o riesgos. 

Es decir, en la mujer embarazada la percepcion de 
que existe el fenomeno de embarazo, va unido con 
el grado de su efecto en ella y su bebe. 

En la Hipotesis 2, se asociaron los beneficios y 
barreras percibidos con el cuidado prenatal y se 
encontro que los beneficios fueron percibidos desde 
un nivel bajo a un nivel moderado, mientras que las 
barreras se percibieron en un nivel moderado. Al 
asociarlas con la variable dependiente, se obtuvo 
significancia estadistica solo con la realizacion de 
cuidados, dato congruente con Bluestein & 
Rutledge (1993) cuando mencionan que los 
beneficios pueden estar determinados por las 
acciones personales, por la ayuda de profesionales 
de salud y por el asesoramiento recibido, no por un 
solo factor o elemento. 

En este estudio los beneficios percibidos se 
ubicaron en un nivel bajo, probablemente por las 
Caracteristicas de educacion, estrato social o 
conocimiento de las embarazadas estudiadas, 
inferencia que concuerda con Stone (1993) quien 
en su estudio encontro que a pesar de controlar la 
barrera financiera, tanto la percepcion de los 
beneficios como de las barreras se afectan por la 
pobreza. 

En el presente estudio la barrera que se report© con 
mayor frecuencia fue la experiencia de haber tenido 
otros hijos y la ambivalencia en el cuidado prenatal; 
la ambivalencia no en el sentido puramente 
psicologico, sino mas bien en la forma en que las 
participantes contestaron las preguntas sobre los 
cuidados y la calificacion obtenida en la escala. En 
estos datos existio incongruencia ya que reportaban 
acudir al Control Prenatal y en la escala obtenian un 
nivel bajo. Esta ultima barrera tambien concuerda 
con los hallazgos de Joyce & Cols., (1983) y York, 
et al. (1993) en donde reportan que una de las 
barreras es la ambivalencia hacia el CPN, 
ubicandola como barrera interna o matema. 

En esta investigacion tambien se puede inferir que 
las sefiales para la accion se percibieron en un nivel 
alto y se asociaron a los cuidados durante el 
embarazo referidos por las participantes del estudio. 



Las sefiales que tuvieron una mayor frecuencia 
fueron la pareja y las recomendaciones de la madre 
o suegra. Al respecto Alcalay, (1993) y Aaronson, 
(1989) coinciden en senalar que los familiares asi 
como la pareja pueden ser fuertes motivadores para 
el cuidado prenatal (p< .001). 

En relacion a los factores modificadores en este 
estudio se encontro una asociacion significativa 
entre el estado civil y religion con el CPN; y la 
escolaridad y el estado civil con los cuidados 
realizados en el embarazo, datos que difieren a lo 
reportado por Torrado, (1988) quien senala que la 
educacion no esta asociada con el cuidado prenatal. 

Otro hallazgo de este estudio fue que la edad, 
multiparidad, y la ocupacion no se asocian al 
cuidado prenatal (p>.05), mientras que Alcalay, 
(1993), Joyce, K. & Cols. (1983) y Rodriguez, & 
Cols.,(1991) evidencian en sus resultados que la 
edad y la multiparidad son determinantes en la 
busqueda de informacion y seguimento de las 
recomendaciones en el cuidado prenatal. 

Finalmente, al correlacionar las variables del MCS, 
las barreras percibidas no mostraron relacion con el 
resto de las variables, dato similar al reportado por 
Tiedje, & Cols., (1992) en donde senalan que las 
barreras actiian de manera independiente de la 
susceptibilidad, severidad y beneficios, concluyendo 
que las barreras muestran multidimensionalidad, 
que aunque no se relaciona a las otras variables es 
un factor de peso en la planeacion de las 
intervenciones para la mujer embarazada. 

CONCLUSIONES 

Despues de analizar los hallazgos del presente 

estudio se concluye: 

5=* Los cuidados prenatales que la embarazada refirio 
realizar, estan asociados a la susceptibilidad, 
severida4 beneficios, barreras y sefiales para la 
accion, no asi el acudir a Control Prenatal. 

>* Las creencias percibidas hacia el cuidado prenatal 
que tuvieron las personas que respondieron, 
permiten identificar que muchas de ellas 
percibieron los beneficios en un nivel bajo, esto 
asociado con las platicas e informacion que se les 
ofrecen en la comunidad, lo que exige mayor 
efectividad y garantia del cumplimiento del 
proposito de los programas prenatales. 

>- La ensenanza del cuidado prenatal a las 



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embarazadas no garantiza su cuidado, mas sin 
embargo, si se fiindamenta en las creencias acerca 
de los cuidados en el embarazo, favorecera un 
cambio en las estrategias de intervencion 
educativa, sobre todo por considerar aspectos 
cualitativos de esta poblacion. 
El apoyo que recibe la embarazada de su entomo 
familiar (pareja, madre, suegra) es importante en 
el seguimiento de los cuidados prenatales, lo cual 
indica que es ideal integrarlos a los programas 
enfocados a esta poblacion para conocer su efecto 
mas de cerca. 

El MCS permitio diferenciar la naturaleza del 
cuidado prenatal (acudir a CPN y cuidados 
realizados en el embarazo), no obstante la 
variable "barreras percibidas" debe ser mas 
extensamente investigada. 



Recomendaoones 

Se recomienda: 

^ Hacer una replica de esta investigacion con el 
proposito de validar la Escala de Creencias de 
Cuidado Prenatal en poblaciones con 
caracteristicas similares. 

>" La utilizacion de los resultados de este estudio 
para establecer metas concretas con respecto a la 
atencion de la mujer, en este caso durante el 
embarazo, parto y matemidad; considerando 
ademas su estilo de vida y su contexto ambiental 
(macro y micro). 

>► Fundamentarse en este tipo de estudios, no para 
disenar o utilizar modelos teoricos nuevos o ya 
establecidos, sino para enriquecer las teorias de 
Enfermeria a traves del desarroUo de la 
investigacion cualitativa fundamental para el 
avance de la disciplina. 



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REFERENCIAS BIBLIOGRAFICAS 



Aaronson N. Perceived and received support: Effects on 
health behavior during pregnancy. Nursing Research . 
1989; 38:1 (4-8). 

Alarcon N. (1993). Salud Reproductiva Rev. Med. IMSS 
31,(47-62). 

Alcalay R, Ghee A, Scrimshaw S. Designing prenatal care 
messages for low income Mexican women. Public Health 
Report . 1993; 108:3 (353-362). 

Becker MH, Drachman RH, Kirsch J. A new approach to 
explaining pshychosocial behavior in low income 
populations. American Journal Public Health . 1974;4:3 
(205-216). 

Bernstein I, Keitch J. Reexamination of Eisen, Zellman 
and McAhster Health BeUef Model Questionnaire. Health 
Education Quarterly . 1991;19:4 (481-493). 

Bluestein D, Rutledge C. Psychosocial determinants of late 
prenatal care: The health belief model. Fam Med . 1993; 
25(269-272). 

Bobadilla JL. Los efectos de la atencion medica en la 
sobrevivencia perinatal. Salud Publica Mex . 1988; 30(3), 
416-431. 

Brown N, Muhlenkamp A, Fox L, Osbom M. The 
relationship among health belief, health values, and health 
promotion activity. Western Journal of Nur Research . 
1993;5:2(155-163). 

Castaneda C. Embarazo, parto y puerperio: conceptos y 
practicas de las parteras en el Estado de Morelos Salud 
Publica Mex. . 1992;34(5), 528-532. 

Comerford FM, Andersen F, Damns K, Merkatz I. Are 
there differences in information given to private and pubUc 
prenatal patients? American Journal Obstetric-Gynecology . 
1993;169:1(155-160). 

Diario Oficial de la Federacion (1993). Norma Oficial 
Mexicana de Emergencia: Atencion a la Mujer durante el 
embarazo, parto y puerperio y del Recien Nacido Sabado 
23 de Oct., 92-109. 

Diario Oficial de la Federacion (1995) Plan Nacional de 
DesarroUo 1995-2000. Mayo de 1995. 

Ibanez Brambila B. (1990). Manual para la Elaboracion de 
Tesis Trillas. Mexico. 

Instituto Nacional de Estadistica, Geografia e Informatica 
(INEGI). (1993). Mortalidad por Causa. Direccion de 
Estadisticas Demograficas y Sociales, Aguascahentes, Ags. 



Joyce K, Diffenbacker G, Greene J, Sorakin Y. Internal 
and external barriers to obtaining prenatal care. Social 
Work in Health Care . 1993;9(2) 89-96. 

Kieffer E, Alexander G, Mor J. Area level predictors use 
of prenatal care in diverse populations. Public Health 
Reports . 1992;107:6(653-658). 

Kroeger A, Luna R. Atencion Primaria de Salud (2a. 
edicion) Mexico: OPS/Pax.; 1992. 

Langer A, Bobadilla JL, Bronfman M, & Avila H. (1988). 
El apoyo psicosocial durante el periodo perinatal Salud 
PublicaMex. 30fn. 81-87. 

Mikhail B. The health belief model: A review and critical 
evaluation of model, research and practice. Ady Nurs 
Sci, 1981; 4:1(65-82). 

Millio N. Stirring the Social Pot. Jona, 1992;22:2(24-29). 

Moysen JS, Ruiz AR. Prevalencia de Bajo Peso al Nacer 
y Factores de Riesgo Asociados[Sumario] U .A.N.L. 
(eds.) Memorias del IX Encuentro de Investigacion 
Biomedica (p. 171 ), Monterrey, N.L. 

Mullen D, Hersey J, Iverson DC. Health behavior models 
compared. Soc. Sci. Med 24 (11), 973-981 (1987), 1990. 

Nemcek MA. Health Beliefs and Preventive Behavior, 
AAOHN Journal . 1990;38:3(127-136). 

Organizacion Panamericana de Salud (OPS) (1986) 
Manual sobre el Enfoque de Riesgo en la Atencion 
Matemo-infantil. Serie Paltex No. 7 p.p. 149-69. 

Polit D, Hungler B. Investigacion Cientifica en Ciencias 
de la Salud (4ta.edici6n)Mexico: Interamericana. 

Porter A. Health beliefs and health practices of pregnant 
women. JOGNN . 1989; May- June, 245-247. 

Potter JE. Utilizacion de los servicios de salud matema en 
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Programa Nacional de Salud. Programa de Atencion 
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Proyecto UNI, Primer Nivel de Atencion (1994) Metas en 
programas de Deteccion, Sanos y Cronicos. 



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Reis J, Mills-Thomas B, Robinson D, Anderson V. An 
inner-city community's perspective on infant mortality and 
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Rinehart W. (ed) (1988). Protegiendo la Vida de las 
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Rodriguez A, Angulo VJ, Vargas G, Martinez AE, & 
Corona A J. (1991). Mortalidad Matema en el Hospital de 
Ginecobstetricia del Centro Medico de Occidente, EMSS: 
Revision de 5 anos Ginec Obst Mex 59, 269-73. 

Rodriguez R, McFarlane J, Mahon J, Fehir J. (1994). De 
Madres a Madres: programa comunitario para un mayor 
acceso a la atencion prenatal. Bol Of Sanit Panam . 116 
(1 ), 82-87. 

Rosenstock I. Historical origins of health belief model. 
Health Education Monographs . 1974; 2(4); 328-335. 

Rosenstock I, Strecher V, Becker MH. Social learning 
theory and health belief model. Health Education 
Quarterly . 1988;15:2(175-183). 

Ruiz AR, Moysen JS, & Ontiveros RM. (1992). Salud 
Reproductiva en el Municipio de Durango, U.A.N.L. (eds.) 
Memorias del Encuentro de Investigacion Biomedica (p. 
176) Monterrey N.L. 



Santos M, Chavarria EVl, & Bosques FJ. (1991). 
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Memorias del JX Encuentro de Investigacion Biomedica 
(p.48) Monterrey, N.L. 

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General de Salud en Materia de Investigacion para la 
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Smith L. (1992) Roles, Risks and responsibihties in 
maternity care: Trainees' beliefs and the effects of 
practice obstetric training. BMJ; 304(1613-1615). 

Stone C. (1993) Commentary on obstacles to prenatal 
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Tiedje LB, Kingry MJ, Stommel M. Patient attitudes 
concerning health behaviors during pregnancy: Initial 
development of a questioimaire. Health Education 
Quarterly . 1992;19:4(481-493). 

Torrado AS. (1988) Perspectivas de la salud matema y 
neonatal en Portugal. Salud Pubhca Mex 30(5), 700-13. 

Viegas QA, Wiknsosatro G, Sahagim GH, Chaturachinda 
K, Ratnam SS. (1992). Matemidad sin riesgo. Foro 
Mundial de la Salud 13(1 ), 58-64. 

York R, WiUiams P, Hazard B. Matemal factors that 
influence inadequate prenatal care. Pubhc Health 
Nursing . 1993; 10:4(24 1-244). 



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Apendice a. Universidad Aut6noma De Nuevo Le6n 
Facultad De Enfermeria, SecretarIa De Post-grado 



Escala De Creencias Sobre el Cuidado Prenata l 
INSTRUCCIONES: Lea cada una de las siguientes 
preguntas y anote o subraye la respuesta que sea apropiada 
para usted. 

No. Cuestionario 

l.Edad 

2. Grado escolar 



1. No Sabe Leer y Escribir 6. Secundaria Incompleta 

2. Sabe Leer y Escribir 7. Preparatoria Completa 

3. PrimariaCompleta 8. Preparatoria Incompleta 

4. Primaria Incompleta 9. Tecnica/Comercio 

5. Secundaria Completa 10. Profesional 



3. ^Practica usted algmia religion? 
l.Si iCual? 

2. No 



7. ^Este es su primer embarazo? 

1. Si 

2. No 

8. ^Cuantos meses de embarazo tiene? 
123456789 

9. ^Acude usted a control de su embarazo? 

1. Si 

2. No 

10. Si en la pregunta anterior contesto afirmativamente, 
^quien le proporciona ese control? 



1 1 . ^Que cuidados realiza usted durante su embarazo? 



12. i,Que le preocupa de su embarazo? 



4. ^Cual es su ocupacion? 

1 . Ama de Casa 

2. Trabajo ^Cual es su actividad? 



5. Estado Civil 

1. Casada 

2. Union Libre 

3. Divorciada 



4. Separada 

5. Viuda 

6. Madre soltera 



6. ^Cuenta usted con servicios de salud? 
l.Si 6Cual?_ 

2. No 



INSTRUCCIONES: Lea cada una de las siguientes 
frases y encierre en tin circulo la respuesta que haya 
seleccionado. 

Las respuestas que usted puede elegir son: 

TA Totalmente de acuerdo 

A De acuerdo 

D En desacuerdo 

TD Totalmente en desacuerdo 



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TA A D TD 



TA A D TD 



13. 



14. 



15. 



17. 



18. 



19. 



20. 



21. 



22. 



23. 



24. 



Creo que mi bebe 
estara sano si acudo a 
la atencion de mi 
embarazo. 



Si ingiero bebidas 
alcoholicas mi bebe no TA 
las toma. 



Si fumo durante mi 
embarazo, a mi bebe no 
le pasa nada 



16. Si mi alimentacion no 
incluye verduras, frutas, 
came y leche, se pueden 
presentar problemas 
que afecten mi salud y la 
de mi bebe. 



Creo que mi embarazo ha ™, . 
sido normal. 



Puedo tener algun 
contratiempo en 
mi embarazo, si no 
cambio mis actividades 
en el hogar. 



Creo que si mi vientre 
(panza) no crece, es seiial ™, ■ 
de que mi bebe no se esta 
desarroUando. 



Creo que el embarazo es 
algo normal en toda 
mujer. 

Si mi bebe deja de 
moverse, puede 
estar enfermo. 



Creo que todos los meses 

de mi embarazo tienen los TA 

mismos peligros. 



Si no me alimento bien, 
puedo desarrollar anemia 
o mi bebe puede nacer , 
antes de tiempo. 

Cuando acudo a la 
atencion de mi embarazo 
puedo recibir informacion 
acerca del cambio en mi 
cuerpo y el desarroUo de 
mi bebe. 



TA A D TD 



25. 



A • D TD 



26. 



TA A D TD 



27. 



TA A D TD 



A D TD 



28. 



29. 



TA A D TD 



A D TD 



TA A D TD 



TA A D TD 



A D TD 



TA A D TD 



34. 



35. 



36. 



TA A D TD 



Cuando recibo platicas o 
charlas sobre el embarazo 
puedo conocer si tengo TA 
algun problema que 
afecte mi embarazo. 



La atencion de mi 
embarazo me ayuda a 
conocer las experiencias 
de otras mujeres 
embarazadas. 

Si mi alimentacion, ropa, 
calzado, y ejercicio no 
son adecuados, pueden 
cambiar si voy a las 
platicas sobre el 
embarazo. 



La atencion del embarazo 
requiere de muchos TA 

gastos 

En ocasiones el horario de 
consulta no me permite TA 
acudir a las citas. 



30. Los servicios de salud 
estan retirados de mi casa. 



TA 



3 1 . Me da vergiienza que me r^ . 
revise un medico. 



32. Creo que si una mujer ha 
tenido varios hijos, ya 
conoce como cuidar su 
embarazo. 



33. Si no voy a la atencion de 
mi embarazo, ni mi bebe rp . 
ni yo tendremos 
problemas. 



A D TD 



TA A D TD 



TA A D TD 



A D TD 

A D TD 

A D TD 

A D TD 



TA A D TD 



A D 



Creo que debo ir a la 
clinica u hospital 
hasta que presente los 
dolores de parto. 



Mi pareja me anima a 

asistir a la atencion de mi TA 

embarazo. 



La orientacion que 
brindan las enfermeras 
me ayuda a cuidar mi 
embarazo. 



TD 



TA A D TD 



A D TD 



TA A D TD 



Page 96 



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S«RS!!5Sl!|!|H?!?W!!!) 



1 



TA A D TD 



37. Creo que la familia debe 

apoyarme durante el TA 

embarazo. 



38. Durante el embarazo debo 
buscar informacion que 

me ayude a cuidarme TA 

(television, radio, 
revistas, periodico). 

39. Mi madre o mi suegra me 
brindan consejos y _, . 
cuidados durante el 
embarazo. 

40. Mi pareja no me deja ir 

sola a la atencion de mi TA 
embarazo. 



A D TD 



D TD 



A D TD 



A D TD 



46.0 


La Nona 


12 


47.5 


La Nona 


19 


54.5 


Los Fresnos 


26 


56.4 


Pueblo 
Nuevo 


13 


57.9 


Pueblo 
Nuevo 


6 


68.7 


Centro 
Apodaca 


3 


71.9 


Cieneguitas 


15 


69.1 


Cieneguitas 


2 



ApendiceC. Relaoon De NOmero De Ageb, 

COLONIA Y NUMERO DE MANZANAS ENCUESTADAS 



Num. De Ageb 


Colonia 


Num. 
Manzanas 


13.6 


Empresas 


1 


17.4 


Empresas 


2 


22.5 


Ejido 


11 


24.4 


LaFe 


10 


27.8 


La 
Encamacion 


3 


32.9 


Roberto 
Espinoza 


21 


33.3 


Lomas del 
Pedregal 


8 


34.8 


Nueva 
Mixcoac 


3 


36.7 


Nueva 
Mixcoac 


3 


38.6 


Nuevo 
Amanecer 


12 


39.0 


Nuevo 
Amanecer 


17 


42.2 


Pueblo 
Nuevo 


28 


43.7 


Pueblo 
Nuevo 


20 


Reproductive Health 







21 Ageb 235 

manzanas 
n= 230 mujeres captadas para el estudio. 



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i 



ApendICE D. ACUERDO DE ParTICIPACi6n En El Si usted esta de acuerdo en participar, le agradezco 

ESTUDIO mucho su colaboracion y le ruego que ponga solo 



Buenos Dias, mi nombre es 



sus iniciales en esta hoja de la cual le dejare una 
copia. Sus ideas seran de gran beneficio. Si Usted 
decide no participar, le agradezco su tiempo. 



Estoy de parte de la Facultad de Enfermeria de la 

UA.N.L., en esta Colonia del Municipio de Apodaca, 

N.L. para realizar un estudio sobre el cuidado del Entrevistador: Acepto Participar: 

embarazo. La informacion de este estudio se utilizara 

en beneficio de esta poblacion. 

Le queremos pedir el favor de hablar sobre sus ideas 

del embarazo. Queremos platicar im rato el dia de ^ , 
hoy, sin interrumpir su trabajo. Podemos dejar de 
platicar cuando Usted asi lo desee. Si hay preguntas 
que usted no quiera contestar o que no entienda, 
digame. 



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HIV-AIDS 



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SEX AND DEATH: ISSUES 

AFFECTING CULTURAL AND 

SEXUAL BEHAVIOR OF LATINA 

WOMEN IN THE ERA OF AIDS 

Gloria Gallegos 
The University of Texas l-lealth Science 

Center at San Antonio 

Chronic Nursing Care/Community Health 

San Antonio, Texas 

ABSTRACT 

The public health message to women with AIDS is 
clear: Las Mujeres No Se Enferman De SID A, 
Simplemente Se Mueren (Women With ADDS Don't 
Get Sick, They Just Die). This message, highly 
visible on a 6-foot poster, may be seen at several 
bus stops in Washington Heights, a Hispanic 
enclave in New York City. 

Why do those condemned to death deny their 
imminent demise? Perhaps because they are not yet 
dead. Destructive behavior in the face of known 
consequences is both difficult and easy to 
understand. Although logic argues that if we know 
the negative consequences of our acts, we ought not 
persist in them, feeling argues that by disassociating 
how we feel from what we do, we can ignore the 
consequences of our actions. 

HIV-infected Mexican-American women are a 
paradigm of the apparent disassociation of thought 
and feeling. They persist in the lethal behaviors and 
risk death to their children. They consent to the 
propagation of death. 

How can AIDS among HIV-positive Mexican- 
American women be contained? How can the 
rational model of control espoused by the North 
American public health establishment be effective 
with a group whose cultural perceptions work 
against it? How can public health professionals 
frame or reframe their message to reach this 
growing population? 



Background of Mexican-American Culture and 
Sexuality 

Mexican-American women must be seen on a 
continuum in relation to their degree of 
acculturation in the United States. At one end of the 
continuum are those who are traditional. They have 
the attributes of the historical Mexican culture, 
especially as rooted in rural, peasant origins. They 
subscribe to traditional institutions and symbols. 
They are Mexicans uprooted from home and 
replanted in the United States (Pavich, 1986). At the 
other end of the continuum are those almost fully 
assimilated into North American culture, with little 
left of their Mexican origins but their Hispanic 
surnames and their distinctive physical appearance. 

In the middle is the group often described as 
bicultural, but representing a range of adherence to 
tradition extending from the literal to the symbolic. 
In this group are those women simultaneously 
attempting to identify with the mainstream North 
American society while retaining elements of the 
cultural set that makes them distinctly Mexican. 

Undergirding any topology of the Mexican- 
American woman, wherever she may be on this 
continuum, is a set of notions deriving from 
Mexican culture historically considered. Mexico, 
under the Conquistadores, became a Catholic 
country. The influence of Catholicism, as expressed 
by Spaniards, was a critical ingredient of the 
culture. What was distinctly Mexican blended with 
what was distinctly Spanish. Octavio Paz (1961) 
characterizes the Spanish attitude toward women as 
"very simple": "Woman is a domesticated wild 
animal, lecherous and sinftil from birth, who must 
be subdued with a stick and guided by the reins of 
religion" (p. 36). Also, Paz describes the mythic 
Mexican woman: 

>* The Mexican woman quite simply has no wiU of her 
own.... She is an answer rather than a question, a 
vibrant and easily worked material that is shaped by 
the imagination and sensuality of the 
male.... Woman is never herself, whether lying 
stretched out or standing up straight, whether naked 
or fiilly clothed. She is an undifferentiated 
manifestation of life, a channel for the universal 
appetite, hi this sense, she has no desire of her own. 
(p. 37) 



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1 



Paz suggests that the ability to become self- 
sacrificing for those she loves is related to a 
woman's social situation as the repository of family 
honor, in the Spanish sense. She becomes a victim, 
bearing her tribulations in silence. 

Thanks to suffering and her ability to endure it 
without protest, she transcends her condition and 
acquires the same attributes as men. (p. 39) 

>- Woman (is) an instrument, sometimes of masculine 
desires, sometimes of the ends assigned to her by 
morality, society, and the law. It must be admitted 
that she participates in their realization only 
passively, as a repository for certain values.... In a 
world made in man's image, woman is only a 
reflection of masculine will and desire, (p. 35) 

>- Womanhood, unlike manhood, is never an end in 
itself (p. 36) 

Culturally, childbirth is considered to be the central 
transformational event in the lives of Mexican 
women. With the birth of her first child, a girl 
becomes a woman capable of the self-sacrifice 
required of a mother. Women gain considerable 
symbolic power because of their association with 
the redemptive power of childbirth (Martin, 1990). 
Thus, a woman's life is centered in her family, the 
primary institution in traditional Mexican culture, to 
which any individual member is subordinated 
(Murillo, 1976). As Pavich (1986) noted, "The 
family is the central institution for socialization, for 
the giving and receiving of help, and for the 
expression of emotions" (pp. 50-51). 

Within the family, its hierarchical structure makes 
roles clear. Girls are educated to be homemakers 
and caretakers of children. They are closely 
watched and chaperoned as they approach 
adolescence, while boys are granted the freedom to 
develop, display, and explore their maleness and 
sexual virility (Pavich, 1986). 

In traditional Mexican culture, where family ties are 
more important than either individuality or the 
marital dyad, Mexican women are socialized to 
value others before themselves, to give without 
question or complaint (Pavich, 1986). Two options 
are open to women in the traditional cultural 
mythology. One choice is to be good : a wife and 
mother, saintly and virginal, devoted to family and 



church, a person whose personal needs are 
secondary (Alvarez and Bean, 1976). The good 
woman is not erotic. She tolerates her husband's 
sexual needs and does not develop her own 
sensuality. Sexual relations are for procreation and 
tolerable because the result is children. The other 
choice is to be bad, one who may be chosen as a 
mistress or playmate. The bad woman exists to 
fulfill men's erotic needs. She is a willing sexual 
partner, responsive to men's sexual prowess 
(Pavich, 1986). 

According to a strict construction of Mexican 
feminine morality, both birth control and abortion 
are publicly condemned. Thus, Mexican women 
make difficult and covert decisions to avail 
themselves of either. 

A Mexican- American woman's life is circumscribed 
by her definition. As a wife, she must support her 
husband. At home, her role is to indulge him and to 
nurture children. His patriarchal position is 
reinforced by her subservience (Pavich, 1986). 
Within traditional Mexican culture, information 
regarding sexuality is nonverbal and indirect. 
Sexual issues often are not discussed even between 
sexual partners. Amaro (1988) found that married 
Hispanic women in Los Angeles had sexual 
relations infrequently and often perceived them as 
not particularly enjoyable. A double standard 
allows Hispanic men to have sex outside of 
marriage, commonly with prostitutes. The Centers 
for Disease Control and Prevention (CDC) have 
found that one of the highest rates of HIV infection 
is among Hispanic prostitutes (CDC, 1986), which is 
likely to result in additional heterosexual 
transmission of the AIDS virus. When asked about 
abstinence, some Hispanic men felt that not having 
sex would be nearly impossible as well as unhealthy 
for them (Marin, 1990). 

The Self and Social Behavior Among Mexican- 
American Women 

All aspects of social motivation are linked to the 
self Self-definition results in behaviors consistent 
with that definition. Some aspects of the self are 
universal; others are extremely culture-specific 
(Triandis, 1989). 

Traditional Mexican culture can be described as 



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collectivistic in contrast to contemporary North 
American culture, which would qualify as 
individualistic. Individualists give priority to 
personal goals over the goals of collectives; 
collectivists either make no distinction between 
personal and collective goals or subordinate 
personal goals to collective ones (Triandis, 1989). 
Additionally, collectivists tend to be concerned 
about the results of their actions on members of 
their in-groups, tending to share resources with in- 
group members, feeling interdependent with in- 
group members, and feeling involved in the lives of 
in-group members (Triandis, 1989). The family, 
the centerpiece of Mexican culture, with the 
tradition of "familismo," is usually considered the 
most important in-group and can present itself as a 
powerful intervention strategy for AIDS prevention. 
The strong familistic orientation of Hispanic culture 
creates a number of obligations as well as a source 
of perceived support in times of trouble. Hispanics 
feel a strong need to consult with other family 
members before making a decision, an obligation to 
help others in the family economically and 
emotionally, and a strong sense of love and 
nurturing toward their children (Marin, 1990). The 
high value placed on children and fertility may 
impede the use of condoms precisely because they 
avoid pregnancy. At the same time, the awareness 
that anything that jeopardizes the woman's life also 
jeopardizes the well-being of her offspring may 
provide the leverage that could persuade her to 
reconsider her feelings against condom use. 

Although the traditional cultural perspective 
deprives Mexican- American women of a "modem" 
concept of self, recent social science research 
questions the degree to which these women remain 
enclosed in a Hispanic worldview impervious to 
contemporary influences. Social science literature 
typically portrays Mexican-American women as 
willingly sacrificing themselves to childbearing 
(Andrade, 1982). The roles of motherhood and 
childbearing are characterized as particularly 
fulfilling. Mexican-American women are 

characterized as assuming a passive, subordinate 
role with their husbands (Amaro, 1988). 

Major criticisms of the literature include studies 
with unrepresentative samples and interpretations of 



findings relying unduly on cultural explanations 
(Amaro, 1988). Despite the wholesale depiction of 
the women as supermothers whose cultural and 
religious traditions dictate submissiveness and 
continuous reproduction, there is great 
heterogeneity even among relatively low-income 
and unacculturated Mexican-American women in 
their attitudes toward motherhood, childbearing, 
sexuality, and unwanted pregnancy and abortion 
(Amaro, 1988). 

Contrary to Catholic doctrine, the majority of 
women in one study (Amaro, 1988) favored and 
currently used contraception to avoid unwanted 
pregnancies. Despite problems in the health care 
delivery system, the fact that women practiced 
contraception in the face of difficulties suggests that 
the women were highly motivated to control family 
size. 

Many social scientists assume that the influence of 
Catholicism has been of overriding importance in 
defining the sex role and reproductive attitudes and 
behaviors of Mexican-American women. This 
assumption has not been supported by studies. 
Being Catholic does not necessarily promote 
traditional reproductive behavior. Women's 
attitudes toward contraception and abortion are 
associated with measures of socioeconomic status 
and religiosity (Amaro, 1988). 

Another myth found in social science, according to 
Cromwell and Ruiz (1979), is that of inevitable 
male dominance in decision making within 
Mexican-American families. "The husband is a 
macho autocrat who rules as an absolute head of the 
family with free authority over wife and children, 
where all major decisions are his responsibility" 
(Alvarez and Bean, 1976, p. 277). A review of four 
studies on both Mexican and Chicano samples failed 
to support this contention. The studies suggest, 
rather, that while wives make the fewest unilateral 
decisions, joint decisions are by far the most 
common in these samples of Mexican and Chicano 
working class people (Cromwell and Ruiz, 1979). 

It is an acknowledged fact that providing effective 
programs stressing ADDS prevention for Hispanic 
communities is a difficult task. Fernandez (1990) 
and Lifshitz (1991) discussed the ingredients of 



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effective AIDS prevention programs addressed to 
Hispanics. Simpatica mandates politeness and 
respect in one's interactions with authority or 
professional figures. It discourages assertiveness, 
direct negative responses, and criticisms. 
Personalismo refers to a preference by Hispanics 
for relationships with others in their social group. 
La platica (literally meaning "the talk") can be 
carried on with health care workers that they trust 
and have had pleasant conversations with. Respeto 
is the need to demonstrate respect, especially for 
authority figures. It also requires that personal 
integrity be maintained in interacting with others. 
This concept can become a handicap by disallowing 
the questioning of authority, even if the potential 
questioner does not understand what the authority is 
telling her. Culturally appropriate interventions can 
be implemented by using messages that contain 
culture-specific concepts that describe the problem, 
consider cultural values, and use appropriate 
channels to disseminate relevant information 
(Fernandez, 1990). 

Acculturation status was found to be associated with 
the knowledge of HTV transmission in a study 
conducted with Hispanics in San Francisco 
(Fernandez, 1990). Messages should emphasize the 
means by which HIV is and is not transmitted and 
the latent nature of the virus. Future studies of 
Hispanics should include measures of acculturation 
when assessing HIV knowledge, beliefs, and 
behaviors as it is probable that these factors may be 
strongly associated with acculturation status (Marin 
and Marin, 1990). 

Credibility is an important issue in selecting 
channels and sources of AIDS information directed 
at Hispanic audiences. Hotlines and printed 
information are perceived as highly believable 
sources of information. Selected individuals with 
closer contact with the disease (e.g., a physician, a 
counselor, or a person with AIDS) are significantly 
perceived as the most credible sources of 
information. Attitude change research supports the 
finding that expertise and trustworthiness are key 
components contributing to the establishment of 
credibility (Marin and Marin, 1990). 



Women AND AIDS 

As a personal risk to women who are poor, black. 
Latino, or outside the law through drug abuse or 
prostitution, AIDS is just one more of many risks 
(Mays and Cochran, 1988): "The key to poor ethnic 
women's response to AIDS is their perceptions of 
its danger relative to the hierarchy of other risks 
present in their lives and the existence of resources 
available to act differently" (p. 951). Even when 
women are able to understand the risk posed by 
AIDS, they may be unable to change their life 
circumstances to avoid it. Risk reduction education 
will succeed in reaching Mexican- American women 
only if it is presented in an appropriate context, that 
is, in a culturally relevant interpersonal decision' 
making framework. The behaviors needing 
modification are linked to these women's sense of 
themselves; to their need for supportive, emotional, 
and social networks; and to a recognition of their 
ethnic and cultural norms (Mays and Cochran, 
1988). 

Specifically tailoring advice to the cultural and 
political realities of Mexican- American women's 
lives is essential for reaching them. Understanding 
the interpersonal communication habits of Mexican- 
Americans, particularly their tendency to be indirect 
and noncommunicative on sexual matters between 
spouses and within the family, is a crucial point of 
departure for framing messages. The sexual naivete 
of Mexican- American women regarding genital and 
reproductive information and means of 
contraception must also be understood. Programs of 
risk reduction need to be developed within the 
natural context of this community (Rappaport, 
1977). The AIDS risk reduction message should 
refrain from using scare tactics. Concrete steps that 
women can take on their own behalf stand the best 
chance of being effected (Soloman and DeLong, 
1986). 

The demographic profile for Hispanic women 
differs by Hispanic ethnic groups in ways having 
important implications for HIV prevention efforts 
(Amaro, 1988). As a group, Hispanic women are 
younger (median age = 26 years) than women in the 
general U.S. population (median age = 32 years). 
Because younger women may be at higher risk for 
HIV infection due to experimentation with drug use 



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and sexual behavior, the markedly younger age of 
Hispanic women may place them at greater risk for 
AIDS. Prevention programs directed to Hispanic 
adolescents and young adult women thus become 
critical (Amaro, 1988). 

The educational level of Hispanic women is lower 
than that of Anglos, with Mexican-American 
women having the lowest level of all Hispanic 
groups. Materials designed specifically for a young 
Mexican-American, poorly educated female 
audience are much needed. Hispanic adolescent 
girls are in and out of school during their early years 
of childbearing. Programs centered not only in 
schools but also in the community and workplace 
are needed to reach them (Amaro, 1988). 

Research indicates important differences in 
contraceptive use between Hispanic and Anglo 
women. Many Hispanic women report never using 
any contraceptive method, not currently using 
contraception, and not having used contraception at 
the time of first intercourse (National Center for 
Health Statistics [NCHS], 1986). Therefore, if AIDS 
prevention is linked to networks of family planning 
counselors and reproductive health care providers, 
many Hispanic women of childbearing age will 
never be reached (Amaro, 1988). Trained 
community health educators providing general 
reproductive and AIDS education in Hispanic 
communities can hope for success if they share the 
same gender, cultural, and linguistic background as 
their target populations (Amaro, 1988). 

AIDS attacks on two fi-onts in Mexican-American 
communities. It attacks the source of social 
cohesion, religion, by requiring that churches 
violate their norms and conventions, and it requires 
that the posture of machismo, male dominance, so 
much a part of the community's defense of its 
embattled position, be modified or abandoned. 
Normally plagues do not strike so cruelly at the few 
defenses — church and ideology — that sustain 
impoverished communities (Perrow and Guillen, 
1990). 

Developing a Risk Prevention Model for 

MexJcan-American Women 

Any risk prevention counseling model developed for 
Mexican-American women needs to reflect an 



understanding of their cultural values and the way 
these values specifically affect their behavior. 
These women have no recent history of emergent 
reproductive rights. They do not see themselves, 
typically, as do women of other Hispanic groups, as 
freestanding in relationship to spouses or partners. 
They are the least well-informed about AIDS and its 
risk. 

To be effective, risk prevention counseling needs to 
address the issue of disassociation of thought from 
action. To address AIDS as a risk, those threatened 
with it must internalize it as a serious enough risk to 
change their behavior. At present, such high-risk 
behaviors as needle sharing and unprotected sex are 
not perceived in this way by many Mexican- 
American women. 

Behavioral models have been proposed as helpful in 
providing a fi-amework for facilitating behavior 
change (Becker, 1974). One such model, the Health 
Belief Model, proposes the following four responses 
to disease avoidance, based on the target person's 
individual beliefs: (1) she is personally susceptible; 

(2) the occurrence of the disease would affect some 
aspect of her life with at least moderate severity; 

(3) taking a particular action would be helpful in 
reducing her susceptibility to her condition; and 

(4) taking a particular action would not entail 
overcoming such important psychological barriers 
as cost, convenience, pain, or embarrassment 
(Nyamathi and Shin, 1990). 

How do responses to these beliefs contribute to the 
effectiveness of a risk reduction program? 
Intervention programs need to identify and correct 
various kinds of misinformation and confusion. 
Hispanic women in the United States are 1 1 times 
more likely than white women to have AIDS (CDC, 
1986). Eighty- four percent of Hispanic pediatric 
AIDS cases were bom to a mother with or at risk of 
AIDS/HIV infection (Nyamathi and Shin, 1990). 

Many Hispanic women perceive AIDS as a low- 
priority problem in comparison with other problems 
they have, such as poverty, unemployment, poor 
health, lack of access to adequate health care, lack 
of health insurance, undocumented status, and 
educational disadvantages (CDC, 1986). Their 
perception of being at risk may be related to their 



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lack of knowledge. Hispanic adolescent girls have 
been found to be less knowledgeable about AIDS 
than whites (Rogers and Williams, 1987). While 
education in and of itself is no guarantee of 
behavioral change, a sense of personal risk is a 
necessary condition for such change. 

The most plausible argument to use in sensitizing 
Mexican- American women of childbearing age to 
AIDS risk is the consequences of the disease for 
their childbearing and caretaking roles. HIV 
infection can affect pregnancy outcomes in both 
mother and child, as well as affect children's lives 
once the mother is either ill or dead (Nyamathi and 
Shin, 1990). Pregnancy is thought to accelerate the 
course of AIDS. If childbearing, the acknowledged 
cultural centerpiece of Mexican- American women's 
identity, is threatened by AIDS, then the risk 
extends beyond the mother's personal consciousness 
to the family. An approach to AIDS prevention 
based on a model of social responsibility rather than 
one based on individualistic preservation may be 
more effective in mobilizing the Hispanic 
community (Mays and Cochran, 1988). 

Health professionals typically depend upon a 
response to health risk that is based on a logical 
understanding. The benefits of condom use are 
difficult to convey to Mexican- American women, 
whose religion condemns them and whose sexual 
dependency on male decision making makes 
requesting their use of condoms of questionable 
value and probability. 

The Health Belief Model proposes that accurate 
information be presented about AIDS and risk 
reduction behaviors, that myths be dispelled, and 
that strategies favoring motivation to change 
behavior be employed. 

For any risk reduction model, the point of departure 
must be an understanding of the values, attitudes, 
beliefs, and traditions of Mexican- American women 
as well as the role motherhood plays as the focus of 
their self-esteem. Conducting focus groups with 
Mexican-American women may be a useful first 
step in designing educational programs for them, as 
these have proven helpful with other women. AIDS 



risk reduction must be a "family" affair for 
Mexican-American women because, like many 
other Hispanic women, they lack real authority over 
the sexual act with their partners. AIDS risk 
reduction programs, as educational efforts, must be 
directed to both their partners and themselves. 
Mexican-American partners may be more 
effectively encouraged to use condoms for the sake 
of their families, rather than for their own sake. 

To reach Mexican-American women, the health 
provider should be aware of the medical practices 
characteristic of their community. Mexican- 
American women use support networks of women 
and alternative healers who can play a critical role 
in AIDS risk reduction. 

One of the predictors of successful change efforts is 
one involving a change agent who provides a 
message of like-to-like. At the very least, Mexican- 
American women need health professionals who are 
Mexican- American and who speak both their literal 
and figurative language. Simply being Mexican- 
American and speaking Spanish is clearly not 
enough for a health provider. The health provider 
also needs to be AIDS literate, comfortable with the 
target clientele, and nonjudgmental. This last 
quality is particularly important because much of 
the risk reduction behavior the health professional 
will suggest may seem, both for her and for her 
clients, counterintuitive from the perspectives of 
religion and culture. 

Mexican- American health professionals, cognizant 
of the cultural burden their clients carry, particularly 
need to empower women. This empowerment will 
help inform them so that they are able to weigh 
responsibly the understood and acknowledged risk 
of their own behaviors, both for their families and 
for themselves. Community resources worth 
developing include self-help groups for AEDS/HIV- 
infected persons, their families, and partners. An 
informal family-like setting of women talking to 
women, with care for young children provided, may 
represent the best hope for this kind of education 
and empowerment. 



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Alvarez D, Bean F. F.thnic Families in America. 
Patterns and Variations . New York: Elsevier North- 
HoUandlnc, 1976. 

Amaro H. Considerations for prevention of HTV 
infection among Hispanic women. Psychology of 
Women Quarterly . 1988;12(429-443). 

Amaro H. Women in the Mexican- American 
commimity: Religion, culture and reproductive 
attitudes and experiences. JoiuTial of Communitv 
Psvcholoev. 1988; 16(6- 19). 

Andrade SJ. Family planning attitudes and practices: 
A function of cultural identification of female 
Mexican- American college students. Dissertation 
Abstracts International . 1982; 40 (University 
Microfihns, No.79-20-077). 

Becker M. The Health Belief Model and Personal 
Health Behavior . New Jersey: Charles B. Stack, 1974. 

Centers for Disease Control and Prevention. Acquired 
immune deficiency syndrome (AIDS) among blacks 
and Hispanics, United States. MMWR. 1986;35(655- 
666). 

Centers for Disease Control and Prevention. 
HIV/AIDS surveillance . Atlanta: U.S. Department of 
Health and Himaan Services, August, 1989. 

Cromwell RE, Ruiz RA. The myth of macho 
dominance in decision making within Mexican and 
Chicano families. Hispanic Journal of Behavioral 
Sciences . 1979;4(355-373). 

Fernandez L. Program evaluation of HTV/ AIDS 
programs of the Public Health Service. Panel-Latinos 
and AIDS: Epidemiological and social research 
perspectives. Presented at the APHA Meeting, New 
York, October 2, 1990. 

Lifshitz A. Critical Cultural Bariers that Bar Meeting 
the Needs of Latinas. SIECUS Report Dec/ Jan 
1991;16-17. 

Marin BV, Marin G. Acculturation on knowledge of 
AIDS and HIV among Hispanics. Hispanic Journal of 
Behavioral Sciences . 1990;12:110-12. 

Marin G, Marin BV. Perceived credibility of channels 
of information and sources of AIDS information 
among Hispanics. AIDS Education and Prevention . 



1990;2:156-63. 

Martin J. Motherhood and power: The production of a 
woman's culture of politics in a Mexican community. 
American Ethnologist . 1990:470-89. 

Mays V, Cochran S. Issues in the perception of AIDS 
risk and risk reduction activities by black and 
Hispanic/Latino women. American Psychologist . 
1988;43:949-57. 

Murillo N. The Mexican-American family. Chicanos. 
Social and Psychological Perspectives. 1976:15-25. 

National Center for Health Statistics. Contraceptive 
use, United States, 1982. Vital and health statistics 
(Series 23, No.l2 DHHS Publication No. 86-1988). 
Washington, DC: U.S. Government Printing Office, 
1986. 

Nyamathi A, Shin D. Designing a culturally sensitive 
AIDS educational program for black and Hispanic 
womenof childbearing age. Perinatal Women's Health 
Issues . 1990; 1:86-97. 

Pavich E. A Chicano perspective on Mexican culture 
and sexuality. Sexuality. Ethnoculture and Social 
Work . 1986:47-65. 

Paz O. The Labyrinth of Solitude: Life and Thought in 
Mexico . New York: Gore Press, 1961. 

Perrow C, Guillen M. The AIDS disaster . New Haven: 
Yale University Press, 1990. 

Rappaport J. Community Psychology: Values. 
Research and Action . New York: Holt, Rinehart & 
Winston, 1977. 

Rogers MF, Williams W. AIDS in Blacks and 
Hispanics: Implications for prevention. Issues in 
Science Technology. 1987;10(12-16). 

Soloman MZ, DeLong W. Recent sexually tiansmitted 
disease prevention efforts and main implications for 
AIDS health education. Health Education Quarterly . 
1986;13(301-316). 

Triandis H. The self and social behavior in differing 
cultural contexts. Psychological Review . 1989:96(506- 
520). 



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^^PONTE TRUCHA^^: A 
CAMPAIGN TO PREVENT AIDS 

^^PONTE TRUCHA'^: UNA 

CAMPANA PARA PREVENIR EL 

SIDA 

Melba Muniz Martelon 

Carlos Del Rio 

Consejo Nacional para la Prevencion y 

Control del 

SIDA, CONSIDA 

Nora Gallegos 

CONADIC 

Jeremias Guzman 

Rodolfo Figueroa 

Secretaria de Relaciones Exteriores 



ABSTRACT 

Purpose 

To provide information on the prevention of 
HIV/AIDS to Mexican women and women of 
Mexican origin on the Mexican-North American 
border as well as in Mexican communities in the 
United States. 

Methodology 

A high incidence of HIV/ AIDS infection was 
observed in Mexican women and women of 
Mexican origin on both sides of the border when 
visiting two American states (Arizona and 
California) and two Mexican ones (Sonora and 
Chihuahua) to learn about the information available 
for the prevention of HIV/AIDS. Most of the 
available information is written in English, which 
when translated literally looses some of the original 
meaning. Also, much of the information is not in 
accordance with the ideology and customs of the 
Mexican communities, making the information less 
effective. 

Results 

We concluded that radio is the most accessible 
medium for this audience and that their preferred 
music is "la grupera." 



Conclusion 

With this information, a radio spot was designed 
using the regional language and expressions and the 
most popular musical group in this area, to be 
broadcast on Spanish language channels in border 
states as well as in the United States where there is 
a large Mexican population. 

Resumen 

Cuando surgio la epidemia del VIH/SEDA los 
trabajos de prevencion y tratamiento se dirigieron 
basicamente a los mal llamados "grupos de riesgo." 
Esto tuvo un efecto doble: la focalizacion y la 
estigmatizacion de ciertos grupos como los grupos 
de homosexuales y las trabajadoras del sexo 
comercial, y por otro, aquellas personas (como las 
mujeres) que no se consideraban dentro de este 
grupo, tenian una falsa sensacion de estar protegidas 
e immunizadas. 

El estereotipo de la buena y mala mujer ha influido 
considerablemente en la percepcion que tiene la 
poblacion de la relacion existente entre la mujer y el 
VIH. Debido a los altos indices de infeccion en 
trabajadoras sexuales de algunos paises, se ha 
llegado a creer que el mayor numero de personas 
con infeccion se concentra en este grupo; a pesar de 
que las estadisticas indican lo contrario. 

Muchas personas creen que el VIH es una 
enfermedad "de mujeres promiscuas," la misma idea 
tienen con respecto a las otras enfermedades de 
transmision sexual. Los primeros carteles 
relacionados con el SIDA advertian a los hombres 
que se cuidaran de "ese tipo de mujeres." 

Los estereotipos continuan dominando en muchos 
lugares. Aunque muchas mujeres contraen la 
infeccion de los hombres, son las mujeres y no sus 
compaiieros las que han sido vistas como la fuente 
de infeccion para los niiios por la transmision 
perinatal. 

La mujer puede contraer el VIH a traves de todas las 
vias de transmision conocidas. El mayor riesgo para 
ella lo representan las relaciones sexuales sin 
utilizar proteccion, con un hombre infectado (el 
contacto puede ser vaginal o anal) que puede ser el 
esposo, un compailero estable, un companero 
ocasional o un cliente; y sin importar si el se 



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contagio debido al uso de drogas inyectadas, una 
transfusion de sangre, o el contacto sexual con otro 
hombre o mujer. 

EL SIDA se ha convertido en la causa principal o 
una de las causas principales de muerte en la mujer 
de edad reproductiva en las principales ciudades de 
la Americas, Europa Occidental y el Africa al sur 
del Sahara. 

La transmision sexual ha sido responsable de la 
inmensa mayoria de casos en la poblacion hetero- 
sexual pero la cantidad de mujeres infectadas 
aumenta proporcionalmente. El aumento de la 
infeccion entre las mujeres se puede apreciar al 
examinar el cambio en la proporcion de los 
hombres y mujeres con VIH/SIDA en paises o 
regiones particulares a medida que pasa el tiempo. 

La infeccion de una mujer por parte de un hombre 
es biologicamente mas factible que la infeccion de 
un hombre por una mujer, esto es por exposicion y 
si los otros factores de riesgo son iguales. Si los 
hombres, en general, mantienen relaciones sexuales 
con mas personas que las mujeres, seran mas las 
mujeres que se vean expuestas al VIH a traves de 
hombres infectados que viceversa. 

El tener hijos o un embarazo no deseado a temprana 
edad, en lugares donde el aborto es clandestino, 
puede presentar tambien un riesgo para las mujeres 
jovenes, en aquellos paises donde no es posible 
garantizar que el suministro de sangre no este 
contaminado, ya que existira el riesgo de infeccion 
a traves de transfusiones en casos de 
complicaciones durante un parto o aborto. No 
existen riesgos comparativos para la poblacion 
joven masculina. 

El VIH ha afectado a todas las clases sociales, pero 
no igualmente a las clases alta y media, pues es 
tambien una mas de las enfermedades de la 
pobreza. 

Las mujeres pobres y las que pertenecen a minorias 
etnicas representan un niimero desproporcionado de 
los casos de VIH/SIDA en mujeres en los paises 
desarroUados. 

En los Estados Unidos las mujeres afectadas y sus 
parejas tienen mayores probabilidades de riesgo de 
contraer VIH/SIDA al ser pobres, pertenecientes a 



una minoria etnica y provenientes de una 
comunidad donde se de el uso de drogas. 

En Mexico, los casos de SIDA en los sectores de 
clase alta y media han ido disminuyendo 
proporcionalmente, mientras que los casos en los 
sectores socioeconomicos pobres han ido en 
aumento. 

El incremento en el niimero de mujeres infectadas 
ha hecho que la proporcion hombre-mujer haya 
disminuido, ya que al inicio afectaba a 25 hombres 
por cada mujer y actualmente es 5 a 1 en promedio. 

Epidemiologia 

La necesidad de crear campanas informativas 
dirigidas especificamente a mujeres en las cuales 
desde una perspectiva de genero se consideren: 

5* Vinculos entre los afectados por el VIH y el SIDA, 

donde viven y como fueron infectados; 
>* Circunstancias y conductas especificas que exponen 

al individuo a la infeccion; 
>■ Factores biologicos que aumentan el riesgo de 

infeccion en caso de verse expuesto al virus; y 
>" El efecto ejercido por factores sociales, economicos 

y politicos. 

Estas campanas deben respetar la idelogia de los 
grupos especificos de mujeres a quien van dirigidos. 

Un grupo especifico de mujeres a quien esta 
dirigido este trabajo esta integrado por mujeres que 
habitan en la zonas de las fi-ontera norte de Mexico 
(Estados de Baja California, Sonora, Chihuahua, 
Coahuila, Nuevo Leon y Tamaulipas) y sur de los 
Estados Unidos (California, Arizona, Nuevo Mexico 
y Texas). 

La dinamica fi"onteriza introduce especificidades 
que deben tenerse en cuenta en la evaluacion de la 
situacion del SIDA asi como en el disefio de 
intervenciones. Uno de los elementos a considerar 
por ser central en esta dinamica, es la migracion. 
No se trata solo de la obvia relacion que se deriva 
del flujo de personas de zonas de baja pre Valencia, 
a otras de alta prevalencia sino de las caracteristicas 
especificas de la fi-ontera como un lugar de paso. 

La evolucion de la migracion y fundamentalmente 
las dificultades adicionales que han aparecido para 
los cruces, obligan a los migrantes potenciales a 
permanecer una temporada en la fi-ontera. Para esta 



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temporada y para afrontar el costo del traslado no se 
tenian provisiones, por lo cual proliferan 
actividades destinadas a financiar este proceso. Es 
asi que una solucion muy recurrida es la practica 
del sexo comercial eventual con todos los riegos 
que este implica para la difusion de enfermedades 
de transmision sexual y en especial del VIH/SIDA 

Las dificultades antes senaladas para el cruce han 
producido un fenomeno adicional: grupos 
importantes de poblacion se radican de manera 
mas o menos defmitiva en ciudades fronterizas 
donde la oferta de trabajo es mayor que en sus 
lugares de origen. Muchos de ellos traen a sus 
familias y, como el ingreso econdmico de un solo 
miembro no es suficiente, ambos conyuges deben 
incorporarse a las actividades productivas. En 
algunos casos tambien los hijos lo hacen. Al arribar 
a la frontera se enfrentan a una sociedad con 
costumbres sexuales mas abiertas y en un estado de 
soledad que los hace proclives a aceptar o buscar 
practicas novedosas que implican un riesgo mayor 
para la infeccion por VIH. Algunos de ellos, luego 
de permanecer muchos anos en Estados Unidos, 
descubren que estan infectados y deciden regresar 
a Mexico. Algunos tambien no completan el viaje 
y se quedan en los estados fronterizos 
sobracargando los servicios de salud locales. 

Con esta idea se realize una encuesta que aborda 
tematicas como: 

> Conocimiento del problema; 

>■ Acceso a medios de comunicacion; 

>► Tipo de lenguaje; 

>- Idioma; 

>- Actitudes; y 

>* Preferencias musicales. 

Con esta informacion se inicio una campana que 
tuviera un mensaje claro, dirigido a mujeres con 
vida sexual activa, utilizando lenguaje local, en 
anuncios que pudieran ser difundidos por la radio e 
interpretados por el grupo musical de su 
preferencia. Asi se origin© la campana "Ponte 
Trucha." 

El anuncio ha tenido una gran aceptacion y esta 
siendo difundido en diferentes estaciones de habla 
hispana en Florida (2 estaciones), Texas (10 
estaciones), Colorado (4 estaciones), California (9), 



Washington (6), Oregon (6), Nueva Orleans (2), 
Arizona (2), Georgia (7), pensamos actualmente en 
producir un anuncio para la television y se han 
distribuido previamente. 



7 Hombres 
1 1 Mujeres 



Esta cadena de contagio se puede 
dar en un mes o en un periodo de 
diez artos. 




Prinopales Vias De Transmisi6n Del VIH 
En Las Mujeres 


Fuentes de exposici^n al contagio 


% del total 


Coito 


85 


Vaginal 


70 


Anal 


15 


Uso de drogas inyectadas 


10 


Transfusion de sangre 


5 



Probabiudades De Infecci6n Con Cada 
ExposiaoN 


|^::::|||?^''''lxposw:i6n ■' 


Probabilidad De 

Infeccion Con Cada 

Infecci6n 


Transfusion de sangre 


> 90% 


Vinculada al embarazo 


20% -41% 


Uso de drogas inyectadas 


0.5% -1.0% 


Otro tipo relacionado con 
agujas 


< 0.5% 



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1 



NUMERO Y PORCENTAJE DE CASOS DE SIDA 

Entre Mujeres Por Cajecoria De EXPOSIOON 
ESTADOS Unidos-Mexico, 1 993 



Frontera Norte 
SIDA 1990 



Pais 


Numero 








ESTADOS UNIDOS 


Uso de drogas intravenosas 


1,458 


Personas con hemofilia 


3 


Contacto heterosexual 


1,474 


Receptoras de transfusion 


90 


Sin riesgo reportado 


299 


Total 


3,324 


MEXICO 


Uso de drogas intravenosas 


2 


Personas con hemofilia 





Contacto heterosexual 


24 


Receptoras de transfusion 


33 


Sin riesgo reportado 


24 


Total 


83 




d 



s P 



I 



I 



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HISPANIC HIV/AIDS CHURCH 
OUTREACH 

Sister Mona Smiley, Ph.D. 

American Red Cross 

San Antonio, Texas 

ABSTRACT 

This paper demonstrates how HTV/AIDS prevention 
education can be presented in Hispanic faith 
communities/churches during services, where 
women form the majority of the congregation, and 
it describes a 6-year ongoing program in which 
initial HTV/AIDS education has been given to more 
than 100,000 adults in both rural and urban 
churches in South Texas during weekend services. 
The principal barriers were largely attitudinal — 
misconceptions about HIV/AIDS from even 
educated clergy and prejudice against women 
speaking in churches. American Red Cross 
educational follow-up helped change attitudes as 
did the presentations. 

Background 

Gallup polls indicate that Americans are very 
religious. A 1994 Gallup poll indicated that among 
Americans, 66% are members of a church; 42% 
attended religious services in any given week; and 
75% of marriages are conducted by pastors, priests, 
or rabbis. 

In January 1994, the American Broadcasting 
Company (ABC) hired Peggy Wehmeyer as 
religion correspondent on "World News Tonight." 
This was a first for a national network, and it had 
taken Peter Jennings 3 years to convince ABC 
executives that a religion correspondent was 
needed. There is resistance in the news 
establishment to covering religion, but, as Jennings 
says, "It is one of the great untapped areas of our 
national life." 

In a baseline study titled "AIDS: Public 
Knowledge, Attitudes, and Behaviors in Texas in 
1988," by Vacalis TD, Shoemaker PJ, and 
McAlister A, it was reported that Hispanics have a 



very high attendance at religious services: 61% 
attend nearly every week, 20% attend 4 to 12 times 
a year, and only 8% report never attending. 
However, Hispanics who attended church services 
most often were the least informed about 
HIV/ AIDS. Most, but not all, Hispanics in South 
Texas are of Mexican origin, and as far as church 
attendance is concerned, like most other groups, 
women form the greatest percentage of the 
congregations. 

Personal Experience 

In this paper, I will share reflections on my 
experiences in HIV/ATDS education in Hispanic 
faith communities in the Archdiocese of San 
Antonio and the Diocese of Victoria, Texas. I am 
now beginning my seventh year in this ministry. I 
have sat in church halls after hundreds of 
presentations to more than 100,000 adults; over 
coffee, menudo, pan de dulce, or tacos I have 
listened to my sisters and brothers tell me how 
HIV/ AIDS has affected them and their loved ones. 

I have presented to huge congregations, as large as 
1,400 at a time, and to 42 people in old theater seats 
in a church that looked like a doll house, where a 
jeep was needed to get to the church because of the 
mud. I chose churches because of the statistics on 
religion and because the two primary Hispanic 
communities in South Texas are La Familia and La 
Iglesia (the family and the church). 

In the beginning, getting into faith communities was 
not easy. Because 75% to 80% of Hispanics are 
Catholic, I began with Archbishop Patrick Flores. 
I had to change my attitude as I approached church 
leadership about speaking on HIV/AIDS in church. 
In general, pastors were not used to women talking 
in church, especially during services; a Catholic nun 
talking about human sexuality in church; or anyone 
talking about sex and sexually transmitted diseases 
(HTV/AIDS is sexually transmitted for the most 
part). Some of the responses, condescension, and 
even insults previously would have caused me to 
hang up the phone, but I learned to tolerate them 
and to bite my tongue because I would not let 
anyone off the hook when it came to ATDS. 
Because Archbishop Flores was very open and 
favorable to this type of education, little by little I 
was able to establish some credibility. 



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I have seen some changes during the past 6 years 
and especially during my 4 years with the American 
Red Cross. I have seen pastors' attitudes change. 
Two churches I could never have gotten into a few 
years ago actually called and invited me last year. 
The rural area churches have called for follow-up 
sessions. So few people visit them that they are 
happy to have someone come back. T got a call a 
few months ago from a rural electric company, and 
when I asked where it had gotten my name, the 
secretary told me, "My boss heard you in church." 
The rural areas are my favorites because, as one 
pastor in Del Rio put it, "We don't have people 
breaking down our doors to speak to our people 
about anything, particularly not about AIDS." 

I have no doubt that what helps me most is my age. 
People figure that at age 60, 1 am harmless, and I 
am for the most part. Another surprise for me when 
I began this work was finding that nuns still had 
credibility, and not just among Catholics but among 
groups of all denominations. All the mainstream 
religions in the United States had issued statements 
on HIV/AIDS, and all of the denominational 
leadership says the same thing: compassion and 
love are the only authentic faith responses to 
HIV/AIDS. 

My church presentations have led to many other 
invitations, from groups as diverse as city public 
service administrations, senior citizens, and hard- 
hat electric workers. Senior citizens are an 
important group, as 1 1% of persons with HTV/AIDS 
are over 50 (and they are not all hemophiliacs). 

During a presentation, I spend the first 5 minutes 
talking about HIV/ AIDS and the rest of the time 
speaking on compassionate faith responses to the 
disease. Sometimes when I speak to nonreligious 
groups, I cannot use scripture, so I fall back on 
Shakespeare's "Merchant of Venice": 

The quality of mercy is not strained 

It droppeth as the gentle rain from heaven 

Upon the place beneath. It is twice blest; 

It blesseth him that gives and him that takes. 



Conclusion 

What has been your attitude, in the secret depths of 
your heart, when you heard of someone with AIDS? 
The late Senator Hubert Humphrey was once asked 
about compassion in politics. He picked up a pencil 
by way of response and said, "Look at this pencil. 
Just as the eraser is only a very small part of this 
pencil and is used only when you make a mistake, 
so compassion is only called upon when things get 
out of hand. The main part of life is competition." 

I am here to tell you that with regard to HIV/AIDS, 
things are out of hand, particularly for minority 
women. African-American women are infected 
nine times more than white women, and Hispanic 
women six times more. As a speaker at a 
Washington, D.C., conference in February 1995 
said, "The letters PWA no longer stand for "Person 
With AIDS,' but for 'Poverty, Women, and AIDS'." 

HIV/AIDS has certainly challenged all major social 
institutions — public health, health care delivery and 
financing, clinical research and drug regulation, 
religious groups, and voluntary and community- 
based organizations. It has even challenged the 
American Red Cross. I believe that it has also 
challenged our expectations of ourselves, our 
beliefs, and our spirituality. We have to become 
"AIDS-friendly people," not to the virus, but to 
those who suffer, to caregivers, and to those who 
grieve. 

I am truly convinced that in the last analysis, which 
is not done in a test tube, in our hearts each of us 
knows that we MS. our brothers' and sisters' keepers. 
Approach your own religious leaders and ask them 
about presentations on HIV/ AIDS in their services. 
If they are not planning one, then they are just 
standing around looking contemporary, and if we do 
not bring up the topic, so are we. 

Excerpts from Statements by Religious 

Leadership 
"The AIDS crisis challenges us profoundly to be the 
Church in deed and in truth: to be the church as a 
healing communitv ." 

—World Council of Churches 



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"The General Board of Global Ministries of the 
United Methodist Church compels the church to 
reach out through prayers, advocacy, education, and 
direct service to provide care and supportive 
ministry to persons with AIDS, their families, and 
friends." 

—United Methodist Church 



"Our Jewish tradition calls upon us to give comfort 
to the sick. We must ensure that people with AIDS 
do not become strangers in their own lands. These 
mitzvoth must be translated into action for our 
time." 

—Union of American Hebrew Congregations 

"The AIDS crisis challenges the church, and 
individual Christians, to a deeper and broader self- 
understanding— to become more fully the 
community of Christ in the world." 

—American Lutheran Church 

"A health crisis of enormous proportions faces the 
church and the world. Denial and prejudice serve 
[only] to make the crisis worse. In the face of this 
reality, the church and its people are called to be a 
community of healing, hope, and compassion." 



—Church of the Brethren 



"As members of the church and society, we must 
reach out with compassion to those exposed to or 
experiencing this disease, and must stand in 
solidarity with them and their families." 

—Catholic Bishops of the United States 

"Resolved, the House of Bishops concurring, that 
this 68th General Convention of the Episcopal 
Church recognizes with love and compassion the 
tragic human suffering and loss of life involved in 
the AIDS epidemic." 

—68th General Convention of the 
Episcopal Church 

"This statement encourages American Baptist 
Churches to 'recognize the AIDS crisis as an 
opportunity for Christ's ministry' and to seek out 
ways to respond in education, prayer, and reaching 
out in compassion." 

—American Baptist Churches 

"The AIDS pandemic calls the church to maturity of 
proclamation, education, service, and advocacy in 
response to the human needs of persons who would 
otherwise be alone and alienated in their suffering. 
This crisis may also grace the church with 
appreciation of the spiritual growth that can be 
experienced by persons facing AIDS." 

—200th General Assembly of the 
Presbyterian Church (USA) 



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HIV/AIDS IN WOMEN: ISSUES 

AND CONSIDERATIONS FOR 

MINORITIES AND BORDER 

COMMUNITIES 

Selina Catala, M.S., LCDC 

University of Texas Health Center 

at San Antonio 

ABSTRACT 

The course of the HTV/AIDS epidemic in the United 
States continues to move more into the heterosexual 
population, presenting special challenges for 
communities, especially in the border areas. Health 
and human services organizations have to shift their 
perspective in providing services to satisfy the 
multifaceted needs of the whole family. Women and 
adolescents are now the two fastest-growing groups 
of infected individuals, and AIDS is now the third 
leading cause of death among women of childbearing 
age, affecting minorities disproportionately. This 
paper discusses the special needs of women, and 
stresses the epidemiological, cultural, and social 
aspects of HIV disease; critical issues regarding 
education, prevention, and intervention; barriers in 
providing services; and special issues and demands 
in border communities. 

Do You Know... 

> What percentage of the total AIDS cases in the 
United States are women ? 

>- How many sexual partners your significant other 
has had in the last 13 years ? 

AIDS IN Females 

> 13% of the total AIDS cases in the United States 
>- Third leading cause of death at childbearing ages 

> 48% infected by injection drug use 

> 36% by heterosexual contact 

> White 25%; Black 54%; Hispanic 2 1 % 

Issues Unique to Women 

>■ Gender and class 

>• Race and social background 

V Cultural and social expectations 



> Multiple roles in the community 

> Sicker than men at diagnosis 

> Different patterns of disease 

Women AND AZJ (ACTG 076) Study 

> Reduced by two-thirds HIV transmission from 
infected pregnant women to their infants 

> Basis for U.S. Public Health Service 
recommendations for HIV-infected women 

>- Requires early identification and education 

> Requires access and coordination of services 

Approaches to Prevention 

> Public information 

> Education 

>> Patient counseling 

Steps to Facilitate Behavioral Change 

> Knowledge 

> Recognition of risk 

>- Perceived vulnerability and fear 

>> Reduction or elimination of alcohol/dmgs 

> Increased impulse control 

> Peer acceptance of change 

Prevention/Risk Reduction 

> Establish confidence and trust 

>* Provide accurate information about risk 
5* Help patient identify "triggers" 

> Empower client to take action 

> Help patient identify alternatives/barriers 
>► Involve partner and/or role-play situation 

Major Issues for Women Living with HIV/AIDS 

> Financial 

>> Emotional, physical, and spiritual 

>> Family and children 

> Relationships and lifestyle changes 

> Education and involvement 
>► Multiple losses 

Challenges in Border Communities 

> Poverty rates 

>► Unemployment 

> Migrant'transient populations 

> Urban/rural communities 

> Shortage of primary care providers 

> Public health issues 

5* Strong cultural and traditional values 



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ANALYSIS OF 

ENVIRONMENTAL FACTORS 

DETERMINING A HIGH RISK 

IN FEMALE AGRICULTURAL 

DAY WORKERS 

ANALISIS DE FACTORES 

AMBIENTALES DE ALTO 

RIESGO OBSTETRICO EN 

TRABAJADORAS AGRICOLAS 

Rodolfo De La Fuente Ruiz 

Coordinador De IMAS Solidaridad 

Delegacion Regional En Baja California 

Jefatura De Prestaciones Medicas 

IMSS Solidaridad 

ABSTRACT 

One hundred cases registered in 1994 in the San 
Quintin Valley were analyzed; 80% of them dealt 
with women agricultural day workers of indigenous 
origin with a maximum of one or two doctor visits 
prior to miscarriage. The women's work days were 
longer than 8 hours and consisted mostly of 
physical activity. They did not have access to a 
health center when they left the fields. 

Conclusions 

The environmental conditions to which the migrant 
agricultural workers were exposed represented an 
important risk factor because of the intense and 
prolonged physical activities combined with 
exploitation in the home. Furthermore, the 
unhealthy setting without even minimal social 
security benefits compounded the risk. 

Las formas de produccion de hortalizas de 
exportacion representan una actividad muy 
importante. En el estado de Baja California, 
Mexico, y especialmente en el Valle de San 
Quintin, situacion que atrae a los campesinos de 
otras regiones mas desprotegidas en busca de 
trabajo; este fenomeno se asocia a una dificultad 
geografica y a una deficiencia de infi-aestructura 
que no permitia acercarles los servicios mas 



indispensables a la poblacion. 

A esto se suman otros factores de tipo sociologico, 
que normalmente no son tomados en cuenta para el 
planteamiento de soluciones, por lo que no ha sido 
posible brindar una buena atencion, a pesar de los 
multiples esfuerzos institucionales. 

Material Y Metodos 

Se realize un estudio transversal analizando 100 
expedientes de altas obstetricas de tres unidades 
medicas ubicadas en el Valle de San Quintin, se 
efectuo observacion no participativa en su medio 
ambiente laboral y familiar y se establecio una 
encuesta respecto a las siguientes variables: origen, 
lengua, edad, escolaridad, frecuencia de atencion 
medica, numero de embarazos, diagnostico y 
condiciones de su habitat familiar y laboral. 

Para determinar el grado de significancia y la 
probabilidad asociada que pudiera haber entre dos 
fenomenos se calculo la X^ (Chi cuadrada) lo que 
nos permitio saber si las frecuencias reales de la 
distribucion diferian o no significativamente. 

Resultados 

Se observe que el 80% de la poblacion fiieron 
indigenas de los cuales 63.7% son mixtecos, 34.9% 
triqui, 7.4% zapotecos y 4% otros. 

Los grupos de edad fueron: 8% menores de 18 aiios, 
68%) de 18 a 34 aiios y 24%) mayores de 34 afios, el 
35% eran analfabetas y solo el 29% saben leer y 
escribir adecuadamente. 

La atencion medica recibida: 30% recibieron menos 
de 3 consultas, 45.6% de 3 a 4 y 24.4% mas de 4. 
Por numero de gesta: 32% primigesta, 47%) de 2 a 5 
y 21% de 5 y mas gestas. Con diagnosticos de: 77% 
atencion de parto, 22% hemorragia precoz del 
embarazo y 1% hipertension que complica el 
embarazo. 

Respecto a las condiciones de trabajo y vivienda se 
observaron 80% malas, 16% regulares y 4% buenas, 
caracterizadas por promiscuidad, hacinamiento, 
escasez de agua, letrinas comunes, una doble 
explotacion laboral y familiar, sin ninguna 
consideracion a las mujeres embarazadas. 



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II 



CONCLUSIONES 

Las condiciones ambientales a las que estan 
expuestas las mujeres jomaleras agricolas 
migrantes, representan un gran factor de riesgo 
obstretico, debido a una extensa y prolongada 
actividad fisica continuando con una explotacion en 
el hogar y un aislamiento social determinado por 
su analfabetismo y su condicion de injdigenas, asi 
como a la falta de atencion medica adecuada y 
oportuna. 

SUGERENOAS 

Para atenuar este problema, es deseable la 
conjuncion de esfuerzos interinstitucionales a traves 
del I.N.I, e I.N.E.A., Secretaria de Trabajo y 



Gobiemo del Estado y Programa IMSS- 
SOLIDARIDAD, con la formacion de "Asistentes 
rurales de salud migrantes" que son personajes de la 
misma comunidad que recibiran una 
capacitacion de dos meses sobre temas de Salud 
Matemo Infantil, alfabetizacion y promocion a la 
salud, los que vigilaran y promoveran la salud en 
sus comunidades, recibiendo un sueldo durante su 
capacitacion y una compensasion mensual al acudir 
cada mes a la unidad medica de control, donde 
recibiran una dotacion minima de insumos y una 
recapacitacion sobre temas especificos. 



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BIBLIOGRAFIA 



Acevedo, Conde Maria Luisa. "Los Mixtecos" En: 
Etnografia Contemporanea de los Pueblos Indigenas de 
Mexico , Region Pacifico, Edit. I.N.I. , Mexico, 1995. 
pag. 81-180. 

Alcala, Elio, Couturier Reyes. Migrantes Mixtecos. "El 
Proceso Migratorio De La Mixteca Baja", Edit. 
I.N.A.H., Mexico, 1994. pag. 165. 

Arispe, Lourdes. "La Migracion por Relevos y la 
Reproduccion Social del Campesinado", En Cuademos 
del CES. 28, El Colegio de Mexico, 1980. pag. 5-38. 

Astorga, Lira, Enrique. Mercado de Trabajo Rural 
en Mexico, Edit. ERA. Mexico, 1985. pag. 126. 

Barbro, Dehlgren. La Mixteca, 4a. ed. Edit. U.N.A.M., 
Mexico, 1990. pag. 303. 

Calero, J., Rey, Metodo Epidemiologico y Salud de la 
Comunidad, Edit. Interamericana, Madrid Espana, 
1992. pag. 580. 

Cisneros, F*uebla, Cesar, A., s/a, Ideologia y Clase 
Obrera en el Campo: Sinaloa. (Documento 
Mimiografiado no publicado), pag. 1-14. 

Conepo, Consejo Estatal de Poblacion. La 
Marginalidad en Baja California, Secretaria General de 
Gobiemo del Estado de B.C., 2a. Edicion Mexico, 
1995. pag. 55. 

Cook, Rebeca J., La Salud de la Mujer y los derechos 
humanos. Editorial. O.P.S., Washington, D.C., 1994. 
pag. 72. 

Corona, Vazquez, Rodolfo,"La Medicion del 
Fen6meno Migratorio en el Censo de Poblacion de 
1990". En: Frontera Norte, Vol. 2, Num. 3, (Enero- 
Junio), Colegio de la Frontera Norte, 1990. pag. 5 - 
30. 

Cruz, Pineiro, Rodolfo, "Mercado de Trabajo y 
Migracion en la Frontera Norte". En: Frontera Norte, 
Vol. 2, Num. 4 (Julio-Diciembre), El Colegio de la 
Frontera Norte, 1990, pag. 61-94. 

Diaz, Polanco Hector, Guerrero Fco. Javier, et al., 
Indigenismo, Modemizacion y Marginalidad ima 
Revision Critica, Editorial Juan Pablo Editores, 4a 
Edicion, Mexico, 1987. pag. 222. 



Ferrara, A., Acebal Eduardo, et. al., Medicina de la 
Comimidad, Editorial Interamericana, Argentina. 1973, 
pag. 239. 

I.M.S.S-Solidaridad Rotafolio de Informacion y 
Evaluacion, 1995, de la U.M.R. Camalii, San Quintin, 
B.C., 1996, Documento de trabajo (inedito). 

I.M.S.S.-Solidaridad, Rotafolio de Informacion y 
Evaluacion 1995, de la U.M.R. Lazaro Cardenas, 1995, 
San Quintin, B.C., 1996, Documento de trabajo 
(inedito). 

I.M.S.S.-Solidaridad, Rotafolio de Informacion y 
Evaluacion 1995, de la U.M.R. Punta Colonett, San 
Quintin, B.C., 1996, Documento de trabajo (inedito). 

Klevens, Joanne E., Sergio R. Munoz. Tamano de 
Muestra Para Estimar Riesgo Atribuible en Estudios 
Transversales. En: Salud Piiblica de Mexico, Mexico., 
Vol. 38, #1, Mexico pag. 37-40. 

Levi, Strauss, Claude, Antropologia Estructural, 3a. 
edicion, Editorial Siglo XXI, Mexico, 1983. pag. 352. 

Martinez, Marielle, P.L., 1976, "Los Caminos de la 
Mano de Obra como Factor de Cambio 
Socioeconomico". En: Cuademos del CES., 27. El 
Colegio de Mexico, pag. 4 - 69. 

Noguez, Vigueras, Miguel. "La Mixteca Baja 
Califomiana". En : Minorias en Baja California, 
Editorial I.N.E.A., Mexico, 1990. pag. 127 - 156. 

Ojeda, de la Pena Norma, "Familias Transfronterizas y 
Trayectoria de Migracion y Trabajo". En: Mujeres 
Migracion y Maquila. (Gonzalez Soledad, Ruiz Olivia, 
Velasco Laura y Ofelia Woo, compiladoras). Colegio 
de Mexico, 1995. 

Oliveira, Orlandina de y Humberto Munoz, 1980, 
"Notas Sobre Algunos Aspectos Teorico- 
Metodologicos.de las Migraciones Intemas y la Fuerza 
de Trabajo". En: Cuademos de Investigacion Social # 
4,U.N.A.M.,pag. 21-23. 

Peek, Peter Y Guy Standing, "Las Politicas de Estado y 
la Migracion de la Mano de Obra", En: Politicas y 
Migracion (Peek Peter y Guy Standing, compiladores). 
Colegio de Mexico, 1989. pag. 1 1-46. 



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TAKING RESPONSIBILITY FOR 

OCCUPATIONAL HEALTH: THE 

POSSIBILITY OF INVOLVING 

MAQUILADORAS IN 

COMMUNITY HEALTH 

PROGRAMS 

Alexandra Bambas, M.P.H.* 

The Institute for Medical Humanities 

University of Texas Medical Branch, 

Galveston 

ABSTRACT 

The North American Free Trade Agreement 
(NAFTA) and the recent devaluation of the peso 
have spurred development of maquiladoras along 
the Mexico-U.S. border. Workers in these 
factories, the majority of whom are women of 
childbearing age, are known to be exposed to 
hazards through their jobs, the environment, and 
their basic living conditions. Because many of 
these women use health services on both sides of 
the border, this phenomenon has binational 
consequences. This paper examines whether 
maquiladoras could be convinced to take greater 
responsibility for the health of the communities 
they have created and the possible health and social 
effects of such programs. The paper also explores 
the associated benefits, disadvantages, and conflicts 
of interest for the community, as well as the shifts 
in the relationships and the balance of power 
between employers and employees. 

Introduction 

NAFTA and the Border Development Project 
(BDP), along with recent devaluations of the peso, 
have spurred the development of assembly plants 
along the Mexico-U.S. border. The relationship 
between these factories, known as maquiladoras, 
and the health conditions of border inhabitants 
suggests that these facilities should take extra 
responsibility for protecting and improving health 



along the border, based on the argument that 
maquiladoras pose special risks to people living in 
this region. Several approaches to increasing 
maquiladora responsibility for border communities 
are possible, including stronger enforcement of 
occupational health and safety and environmental 
laws, an increase' in taxes paid by the factories, and 
direct involvement of the factories in community 
health projects. Each of these possibilities features 
particular political, economic, social, and health 
consequences that make them more or less feasible. 

The Rise of the Maquiladoras 

In 1965, the Mexican Government began BDP as 
part of a comprehensive effort to increase 
international investment in Mexico. Specifically, 
BDP sought to improve economic opportunities for 
Mexicans living along the Mexico-U.S. border by 
encouraging intemational assembly plants to locate 
in this historically underdeveloped region. NAFTA 
has continued this work, and thousands of Mexican 
citizens have flocked to the border in search of jobs 
unavailable in other parts of Mexico. 

Because maquiladoras pay reduced domestic taxes 
and no import or export taxes (under provisions of 
BDP and NAFTA), and because labor costs in 
Mexico are among the lowest in the world,' more 
than 2,500 factories currently operate along the 
border, employing more than 750,000 people. 
These industries constitute Mexico's second largest 
source of foreign capital, and BDP has come to be 
regarded as a significant stabilizing force in the 
Mexican economy (Stoddard, 1990). 

Because trade agreements such as NAFTA are 
likely to increase the number of maquiladoras, the 
Mexican economy is likely to become more 
dependent on foreign investment. Moreover, 
contrary to the predictions of NAFTA's supporters, 
maquiladoras have not proliferated in the interior of 
the country but rather are multiplying along the 
border due to the devaluation of the peso. 
Consequently, migration to the Mexico-U.S. border 
has accelerated, and foreign-owned maquiladoras 



The author wishes to thank Kirk Smith for his valuable 
suggestions in preparing this manuscript. 



'The minimum wage in Mexico before the most recent 
devaluations was about $4.50 per day (Moure-Eraso, et al., 
1994; Weiss, 1992). 



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wield increasing political and economic power in 
Mexico. 

Maquiladoras and the Health of the Border 
Population 

Unfortunately, improved economic opportunities 
have not necessarily translated into better health for 
Mexican citizens. Although the health situation of 
Mexicans in general is below par, the health of the 
border population is especially threatened by the 
proliferation of maquiladoras that increase the 
number of hazardous workplaces, pollute the 
environment, and contribute to an excessive 
population density. 

First, employees are often subjected to difficult 
working conditions, including poor ventilation, few 
rest periods, excessive noise levels, unsafe 
machinery, and long hours of microscopic assembly 
work. Work in electronic processing plants is 
particularly insidious because it often involves 
exposing women of childbearing age (who make up 
the majority of maquiladora employees) to solvents, 
metals, epoxy resins, and acids and bases that are 
potentially genotoxic and/or fetotoxic (Fuentes and 
Ehrenreich, 1983; Hovell, et al., 1988; Huel, 
Mergler, and Bowler, 1990). 

Second, the health threats of these plants extend to 
the greater community through environmental 
pollution. Environmental Protection Agency (EPA) 
hazardous waste records for 1989 show that only 20 
maquiladoras out of more than 1,000 complied with 
the U.S.-Mexico agreement that hazardous wastes 
generated by U.S. firms in Mexico be shipped back 
to the United States (Sanchez, 1989). 

Much is dumped illegally (Bath, 1991; McNamara, 
1992). Additionally, unregulated landfills that 
catch fire, carcinogens produced in electronics 
manufacturing, open burning, and emissions from 
cement plants and power stations pollute the 
atmosphere. Pesticides, raw sewage, and toxic 
wastes enter water supplies that border residents 
must drink for lack of an alternative source (Bath, 
1991; Cech and Essman, 1992; Robinson and 
Dabrowski, 1993). Although the 1988 Lev 
Ecologica (Ecology Law^ gave the SEDESOL (the 
Mexican EPA) increased regulatory authority over 
the maquiladoras and NAFTA included a specific 



"green" side agreement (called the North American 
Agreement on Environmental Cooperation) that 
established boards to investigate and address 
environmental problems, little money is available 
for cleanup and enforcement of environmental laws 
is sporadic at best (Jones, 1995; Moure-Eraso, et al., 
1994). 

Finally, the growth of maquiladoras has contributed 
to a population boom along the border. The region's 
population increased 31% from 1980 (2,967,566) to 
1990 (3,889,578), and this trend is expected to 
continue into the 21st century (Williams, Eastman, 
and Peach, 1994). Residents often settle in informal 
communities known as colonias, which lack city 
management and infrastructure. As a result, many 
border inhabitants are without access to public 
services, including police and fire departments, 
sewage systems and freatment plants, water 
purification plants, utilities, and decent housing. 

These working and living conditions harbor dire 
consequences for the health of border residents. 
Sixty percent of garment and electronic maquiladora 
workers who are young women of reproductive age 
often have low birthweight babies (Eskenazi, 
Guendelman, and Elkin, 1993). Particular types of 
manufacturing are associated with specific worker 
problems: workers in electronic assembly plants are 
likely to experience headaches, allergies, eye 
problems, and adverse pregnancy outcomes, while 
textile and apparel workers experience high rates of 
eye, lung, and skin disorders and often suffer hand 
injuries and musculoskeletal disorders (Guendelman 
and Silber, 1993). Conditions in the colonias also 
encourage transmission of infectious diseases and 
development of parasitic infections; for example, 
the incidence of Third World diseases such as 
cholera and dengue fever has increased tenfold in 
Mexico over the past year (Fineman, 1995; Jones, 
1995). At the same time, the border has higher rates 
of death than other parts of Mexico from 
tuberculosis, diabetes, cerebrovascular diseases, 
malignant tumors, childbirth, and heart 
disease— health problems usually associated with 
industrialized nations (Reiss, 1978). As one 
Mexican official acknowledged, "Mexico has the 
health problems of most developing countries, as 



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well as the health problems of developed countries" 
(as cited in Moure-Eraso, et al., 1994).^ 

The Mexican Government recognizes the threat to 
the health of its citizens along the border and 
responds to illness and injury through the 
nationalized health care system. However, 
although the border area enjoys better standards of 
care than many rural areas of Mexico, the 
government's response is limited insofar as it treats 
individual illness and disease but does not address 
larger problems of the environment, housing, or 
living conditions. Furthermore, the system 
discriminates by providing different levels of care 
to individuals depending on their working 
status— formal employees, informal employees, or 
unemployed. 

Because only about 4% of the population can afford 
private insurance, the majority of Mexican citizens 
rely on the government for health services. 
Maquiladora workers, who are classified as formal 
salaried workers, are covered under the Mexican 
social insurance program, or IMSS, which collects 
money from employees, employers, the State, and 
the Federal government to provide noncash and 
cash benefits to workers. Noncash benefits include 
general and specialized care, surgery, maternity 
care, hospitalization, laboratory services, dental 
care, and medicine for the employee, his or her 
spouse, children below the age of 16, and parents, 
whereas cash benefits include paid sickness and 
maternity leave. 

However, some maquiladoras avoid paying 
employee benefits by hiring "temporary" workers, 
who are uninsured informal employees. These 
employees have much more limited access to 
services, with access through either the Federal 
District Department or the National System for 
Integral Family Development. These governmental 
organizations respectively manage hospitals and 
primary health care centers for the uninsured 
population and serve the uninsured urban 
infant-maternal population with nutrition, health 
care, and other services for low flat-rate user fees. 



Quote by Sergio Reyes Lujan, Undersecretary of Ecology 
of the Mexican Secretaria de Desarollo Urbano y Ecologia. 



Services for those with social insurance are 
significantly better than those available to informal 
employees who are wholly dependent on public 
services for health care. However, all-day waits are 
not uncommon in any government program 
whatever the patient's employment status. Services 
for the insured are also limited; for example, the 
social security system in Matamoros has few 
specialists and only 60 hospital beds for a city of 
200,000 people. Patients must travel 200 miles for 
many specialized treatments (Moure-Eraso, et al., 
1994). 

The border's higher mortality and morbidity rates 
are simple gauges of the government's inability to 
compensate for the health dangers of living in the 
region. However, whether or not the government's 
efforts on the border are sufficient, there remains a 
broader issue: should the Mexican Government be 
solely responsible for the health needs of 
maquiladora employees and surrounding 
communities, or should the companies operating 
these facilities shoulder more of the burden of 
responding to injury and illness on the border, 
especially when these threats are fairly easy to 
prevent (such as environmental toxins or safety 
lapses) and are imposed by a particular, identifiable 
segment of employers? 

Increasing Maquiladora Responsibiuiy for 
Employee and Community Health 

There are compelling reasons to suggest that 
maquiladoras should provide for employee health 
care. They employ large numbers of people in a 
small geographical area; they are familiar with the 
particular health risks posed to employees and the 
community; and, perhaps most important, they have 
the financial means to support such programs. The 
Mexican Government, in contrast, is experiencing a 
financial crisis, having been forced to slash the 
Federal budget by nearly 10% in 1995 due to 
currency devaluations and a massive economic 
contraction in 1994. Arguments to support 
increased maquiladora participation in the health of 
the border population can also be made based on 
efficiency since much of the bureaucracy in the 
National Health System could be eliminated, clinics 
could be based in the factories near populations at 
risk, and continuity of care could be improved. 



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One way to increase the maquiladoras' 
responsibility for their workers and communities 
would be to improve enforcement of current 
occupational safety and health standards and 
environmental safeguards. Present government 
standards require a relatively high level of 
occupational safety and health conditions to be 
maintained in factories. In fact, these standards are 
technically more strict than U.S. standards (Jones, 
1995). Environmental regulations are reportedly 
comparable to U.S. standards (VanderMeer, 1993). 

Although the government maintains an appearance 
of oversight, enforcement occurs at a low level. 
Current reports indicate that inspections of factories 
are highly ineffective, and safety standards are 
frequently violated. Indeed, factories are often 
given warning of and control over inspections to 
guarantee that infractions will not be discovered. 
Cases have been reported in which companies 
forced an injured worker to sign a statement 
relieving the company of fault, or be punished by 
employment termination (Dwyer, 1994; 
Fernandez-Kelly, 1983; Jones, 1995). Reports such 
as these introduce special concern for the effect of 
employer-employee relations on protecting and 
promoting workers' health. 

The possibility of strengthening the enforcement of 
health, safety, and environmental standards may be 
precluded by deep-seated political and economic 
factors. Enforcement would require the full support 
of a government that currently has serious 
obligations both to its citizens and to foreign 
investors, whose interests do not always overlap. 
On the one hand, the Mexican Government is 
obligated by the constitution to promote the health 
interests of Mexican citizens.^ Neglecting this 
obligation by disregarding occupational safety and 
health and environmental standards undermines the 
government's constitutional authority. On the other 
hand, to relieve the poverty of the people, economic 
development must be encouraged. Consequently, 
the international companies that provide work for 



The Mexican Constitution specifically charges the 
Government with the duty to provide for the health needs of all 
citizens and establishes health as a right of the people. 



citizens must be accommodated for Mexico to 
maintain its status as a profitable locale for industry. 

Complying with public safety laws, such as safely 
disposing of toxic wastes or allowing frequent 
breaks for workers, is expensive. Enforcing safety 
standards at maquiladoras would reduce Mexico's 
global competitiveness in one of its largest 
industries. Some international health and economic 
theorists claim that long-term benefits will accrue 
from economic development, including improved 
health and welfare, and therefore current abuses and 
harms should be tolerated (AUeyne, 1995; World 
Bank, 1993). The government, then, is in the 
difficult position of balancing public health with the 
economy, as well as short- and long-term benefits to 
both. The possibility of improving border health 
through governmental enforcement of occupational 
health and safety and environmental laws thus 
seems unlikely given the political fallout from such 
an effort. 

A second approach to increasing the maquiladoras' 
health care responsibilities would be to reexamine 
the distribution of tax burdens among businesses in 
Mexico. Mexico lures foreign-owned factories with 
the lack of tax burdens, a benefit the government 
continues to expand, as well as with NAFTA's 
suspension of import/export taxes. Through BDP 
and NAFTA, assembly plants along the border are 
relieved of a significant portion of their tax burden; 
they pay no taxes on goods assem.bled in the country 
nor import/export taxes. By requiring maquiladoras 
to pay taxes in proportion to those paid by other 
Mexican businesses, these companies would be 
contributing their share to citizens' welfare. Indeed, 
paying taxes comparable to other businesses may 
not go far enough. If these factories have a special 
burden because of the health threats they pose, they 
would need to surpass the obligations of other 
businesses. 

On a pragmatic level, how much the increased tax 
payments would ultimately benefit the health 
conditions of border dwellers is indeterminate 
because only a firaction of such taxes would go to 
the Ministry of Health, and any resulting 
expenditures would likely address treatment of 
existing conditions rather than prevention of injury 
and illness. Moreover, improving health services 



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along the border through taxation would at best 
establish only an indirect link between the factories 
and border dwellers' health and would not be the 
most efficient means of encouraging factories to 
develop a sense of responsibility for, and 
investment in, the health of their workers and the 
community. 

A third way to increase the level of responsibility of 
maquiladoras for their workers and communities 
would be to convince the operators of these 
facilities that they should voluntarily become 
involved in community health projects on a grass 
roots level. Justice requires that some of the 
financial benefits these companies have reaped 
should be allocated to the welfare of those who 
have made those profits possible— an argument of 
reciprocity. Although this appeal to justice may 
convince some, politics demand pragmatic 
arguments. Therefore, one might highlight 
examples of socially responsible companies that are 
also financially successful, demonstrate the manner 
in which their finances and reputation have 
benefited from such projects, and provide specific 
plans for start-up health care projects. 

Consider the example of the Honeywell plant. In 
1994, in what it claimed to be a dramatic and 
unusual public gesture of solidarity with the 
working class, the Honeywell Corporation opened 
an on-site health clinic at its factory in Tijuana. It 
was staffed by a part-time doctor and full-time 
nurse, a volunteer part-time doctor for evenings and 
weekends, and a visiting dentist. The clinic 
provides primary and preventive health services, 
maternal/infant care, health maintenance, 
education, and first aid to employees and their 
families free of charge, and to community members 
for a token 10 peso fee (approximately U.S. $1.75); 
it estimates that it is providing limited services for 
approximately 3,000 people. The project is a 
combined effort of Honeywell, IMSS, and the 
Mexican Department of Family Care, as well as 
some private individuals. However, the clinic is 
intended only to supplement, not replace, services 
currently provided by the Mexican Government 
through IMSS (Gaertnier, 1994; Muller, 1995). 

The company has not decreased its payments to the 
government for employee insurance and has, in 



essence, donated these clinic services to employees 
and the community. Honeywell cites an increasing 
need for loyal, skilled workers and competition for 
employees, as well as a long-term interest in the 
community, as its motivations. It is possible that 
with increases in the number and size of factories 
along the border, competition for employees will 
increase, and such clinics could become part of a 
factory's typical benefits package. Services too 
could expand. Although Honeywell is not formally 
assuming responsibility for employees' health care 
and continues to participate in government- 
sponsored services, the Honeywell clinic certainly 
demonsfrates an industry interest in more direct 
delivery of care to employees and consequent 
benefits to the company. 

With careful planning and oversight, as well as a 
good faith commitment from industry, a health care 
services arrangement could benefit workers, 
companies, and the greater border community. 
However, a less sincere effort might result in 
exploitation of individuals and of Mexico, and 
ultimately worsen conditions for all involved. 
Using the Honeywell clinic as a model, let us 
explore the possible benefits and disadvantages of 
participation by private companies in the health care 
of their employees. 

The Health and Social Consequences of 
Encouraging Maquiiadoras to Become Active 
IN Health Issues 

The most obvious benefit that might accrue to 
workers and to the greater community is that health 
services and presumably individuals' health would 
improve with the greater level of access to care that 
an on-site clinic could provide. Illnesses or injuries 
heretofore neglected due to the time and 
inefficiency involved in visiting an overworked 
government clinic could be addressed more quickly, 
as soon as they are recognized, and basic preventive 
services could be administered more efficiently. In 
the long run, by strengthening preventive care and 
addressing illnesses and injuries quickly, employees 
would lose fewer days of work, leading to increased 
productivity, and raising worker salaries and 
company profits. Furthermore, employee turnover 
(which is currently up to 180% in places) would 



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likely decrease, saving the company training and 
hiring costs (Moure-Eraso, et al., 1994), 

Benefits to workers are not limited to direct effects 
such as improved access to clinics. Certain indirect 
advantages are also likely to accrue if 
improvements are made in individuals' health 
situations. For instance, if companies believe that 
their efforts translate into increased profits, they 
could develop an increased sense of responsibility 
in areas other than primary health care, such as 
environmental health or infrastructure projects such 
as sewer systems or water purification plants.'' 
Improvements in occupational health and safety 
standards might pique the interest of management 
if it recognizes that job hazards are linked to worker 
productivity and contentment. A greater sense of 
shared interest in the community as well as 
cooperation between workers and employers could 
ultimately result in mutually beneficial relations 
between the two parties, rather than the sense of 
antagonism and distrust that has evolved between 
labor and management in many maquiladoras. 

Another possible benefit for the company is 
heightened competitiveness for workers. In the 
past, the modest number of factories and seemingly 
limitless supply of willing hands have allowed 
maquiladoras tremendous discretion in hiring and 
firing practices. However, because the number of 
factories has increased greatly, and many jobs now 
require training and special skills, competition for 
qualified workers has increased dramatically. 
Providing a clinic as a company benefit would 
certainly improve a factory's desirability. In fact, if 
enough companies begin to offer an on-site clinic, 
it could create sufficient pressure for others to offer 
the same benefit simply to remain competitive. 





Possible Benefits 


Possible Harms 


TO 


improved health 


increased control of 


WORKERS 


services 


company over 


OR THE 




workers 


COMMUNITY 


increased salary 






potential 


internalized safety & 
health violations 




increased factory 






responsibility in other 


decreased 




areas (e.g., 


compensation for 




environmental health, 


worker injury. 




service infrastructure) 


illness 




strengthened long- 


weakened 




term commitment of 


government's role in 




factory to community 


health care: services, 
authority, enforcing 




strengthened 


standards 




community ties, labor 






relations 


weakened role of 
unions 

worsened labor 
relations 


TO THE 


strengthened 


increased cost 


COMPANY 


competitiveness for 






workers 


decreased flexibility 
for relocation 




increased productivity 






and profits 






improved public 






relations 






improved labor 






relations 





''This and many of the following benefits would not occur 
through strengthening enforcement of standards or increasing 
taxes. 



In a similar vein, as maquiladoras have come under 
heavy criticism for alleged abuses, these activities 
could do much to improve public relations both 
nationally and internationally. In this way, 
companies might use the clinic as advertisement, 
publicizing their employee-friendly practices to 
increase their public appeal. 

Finally, taking increased responsibility for 
employee and community health would demonstrate 
the maquiladoras' sense of long-term commitment 
to the communities in which they operate. Episodes 
in which workers have returned to work on Monday 
morning to find that their factory had packed up and 
left town over the weekend— without issuing notice, 
without issuing paychecks— have left many 
maquiladora employees feeling insecure and 
distrustful of their foreign employers. Deepening 
companies' investment in communities would lessen 
employees' worries about recurrences of such 
episodes. 

Attractive as the above benefits appear, one should 
not call for increased maquiladora participation in 
border health care without first considering possible 



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detrimental effects. The cost of setting up and 
running on-site clinics would constitute the primary 
disadvantage to employers, although employee 
retention and increased productivity could partially 
or completely offset that cost. Additionally, while 
this project would create a stronger sense of 
stability in these communities, the decreased level 
of flexibility for factory relocation stemming from 
greater financial investment in the community may 
be seen as limiting to companies that wish to use 
high mobility to their advantage. 

More important are the possible corrosive effects 
on the status of employees that might result from a 
lack of good faith and sincerity on the part of the 
company. Management wields considerable control 
over workers in Mexico.^ In a country where 
unions have never exerted significant political 
power, giving companies control over their workers' 
access to clinical care would fiirther sfrengthen the 
hand of management, which could then exploit this 
control to prevent workers from organizing to take 
care of themselves.^ 

Furthermore, reports indicate that some factories 
suppress their workers' injury claims to keep 
insurance costs low and limit liability for recovery 
and compensation costs. Not only do these 
incidents unfairly harm workers financially, they 
also compromise the health of the workers. 
Currently, this practice is limited by the fact that 
employees seek health care through an agency not 
controlled by the company— that is, 
government- sponsored clinics. If the system were 
such that factories became the primary health care 
provider, the opportunity to falsify reports and 
coerce workers and caregivers could increase. And 
even if government-sponsored clinics remained 
available, workers could easily be "convinced" to 
use the company clinic to cover injuries. 



Many of the possible disadvantages mentioned here are 
directly related to the close oversight management would now 
have regarding employees; these would have less possibility of 
becoming a problem with either increasing enforcement of 
standards or increasing taxes. 

^In Mexico, few unions exist, few workers are members, 
and the representatives are usually appointed by industry 
(Dwyer, 1994). 



Consequently, safety and health violations might 
become internalized and frirther deteriorate because 
no outside agency would be alerted to the abuses, 
and less public accountability would exist. 

Mexico's history of compliance with and 
enforcement of policies is not impressive. If the 
government were to allow businesses even more 
confrol over employees with the knowledge that 
health and safety standards would erode as a result, 
the government would clearly be abrogating its 
responsibility. Government would be sending a 
message to businesses that the health and even the 
lives of its citizens are not important. Any of the 
abuses mentioned above, if they were to transpire, 
would worsen relations between labor and 
management. 

Finally, one particular long-term concern should be 
considered before undertaking a project that 
duplicates a government service. Although an on- 
site health care clinic might be conceived as a 
supplement to, and not a replacement of, the IMSS 
or other federally sponsored health care services, it 
is possible that the project could eventually 
undermine the government's authority by subverting 
its role in health care or compromising its role in 
enforcing health and safety standards. Employees 
could come to depend on company services rather 
than government services. Such dependence could 
have a significant social disadvantage. In the past, 
Mexican citizens have turned to the government, the 
representative of the people, to resolve social justice 
problems. While citizens might still direct their 
objections to the government, government will have 
less ability to resolve the problem, even when it 
recognizes the validity of the argument and wants to 
correct the injustice, if it cannot enforce regulations 
and if it is not directly overseeing the care provided. 

The point of mentioning these possible 
disadvantages is not to advise against encouraging 
maquiladoras to become more involved in the 
welfare of their employees, but to identify some of 
the obstacles to making such a project successfril. 
Although maquiladoras have increasingly offered 
workers benefits, such as child care services and 
employee cafeterias, an on-site, factory-run health 
care clinic would present special challenges that 
must be addressed. 



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Other methods of improving health along the border 
have been tried and are showing signs of limited 
success: several nongovernmental organizations 
link needy individuals with services, and one labor 
union has purchased a private clinic and subsidizes 
half of the workers' bills (Moure-Eraso, et al., 
1994). Unfortunately, these methods do not place 
the burden of care on those responsible for many of 
the injuries and illnesses. 

Forcing maquiladoras to provide health services 
would defeat the larger purpose of this 
endeavor— to foster a sense of accountability to the 
community— and would invite abuses of the system 
and workers. Only by approaching factories 
directly and appealing to them on a voluntary basis 
can a good faith effort be encouraged. 
Voluntariness would by no means guarantee that 
the welfare of workers is high in the minds of 



employers, but it could be a start to building the 
trust that has been eroded over the years due to the 
injury, illness, and death incurred through factory 
work and environmental pollution, as well as by 
unfulfilled promises of prosperity. 

The health problems of the border will endure 
unless the major political and economic forces of 
the area agree to organize and cooperate to end 
them. Because the number of maquiladoras and 
competition for skilled workers has increased 
substantially over the past 2 years, these companies 
may now be better prepared to respond in a 
thoughtful and humane maimer to the crisis of 
border health. As health care workers and critics, it 
is our responsibility to encourage this outcome by 
investigating possible solutions and assisting in the 
translation of those solutions into practice. 



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AUeyne G. Prospects and challenges for health in the 
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industrial integration . Boulder, CO: Westview, 1991. 

Cech I, Essman A. Water sanitation practices on the 
Texas-Mexico border: Implications for physicians on 
both sides. Southern Medical Journal . 1992; 
85:11(1053-1064). 

DwyerA. On the line: Life on the U.S.-Mexican 
border . London: Latin American Bureau, 1994. 

Eskenazi B, Guendelman S, Elkin E. A preliminary 
study of reproductive outcomes of female maquiladora 
workers in Tijuana, Mexico. American Journal of 
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Fernandez-Kelly MP. For we are sold. I and my 
people . Albany: State University of New York Press, 
1983. 

Fineman M. Economic ills infect health of Mexicans. 
New York Times. October 1, 1995:A8. 

Fuentes A, Ehrenreich B. Women in the global 
factory . Boston: South End Press, 1983. 

Gaertnier, M. Honeywell opens community health 
care clinic in Mexico. PR Newswire . July 14, 1994. 

Guendelman S, Silber M. The health consequences of 
maquiladora work: Women on the U.S.-Mexican 
border. American Journal of Public Health . 1993; 

83:1(37-44). 

Hovell MF, Sipan C, Hofstetter CR, DuBois BC, Krefft 
A, Conway J, Jasis M, Isaacs HL. Occupational health 
risks for Mexican women: The case of the 
maquiladora along the Mexican-United States border. 
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1988;18(617-627). 

Huel G, Mergler D, Bowler R. Evidence for adverse 
reproductive outcomes among women microelectronic 
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Jones R. Border health: Current situation and future 
predictions along the U.S. /Mexico border . Presented at 
the Southwest Social Science Association Meeting, 
Dallas, TX, March 1995. 



Koechlin T, Larudee M. The High Cost of NAFTA. 
Challenge, 1992. September/October (19-26). 

McNamara V. Maquiladoras breed disease, expert 
says. The Houston Post . Dec. 10, 1992:D2. 

Mesa-Lago C. Health Care for the Poor in Latin 
America and the Caribbean. Washington, DC. Pan- 
American Health Organization, 1992. 

Moure-Eraso R, Wilcox M, Punnett L, Copeland L, 
Levenstein C. Back to the future: Sweatshop 
conditions on the Mexico-U.S. border. I. Community 
health impact of maquiladora industrial activity. 
American Journal of Industrial Medicine . 
1994;25(3 11-324). 

Muller A (Administrative Supervisor of the Honeywell 
plant in Tijuana). Interview by A. Bambas, July 18, 
1995. 

Reiss RL. Considerations on the health status along 
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across the border: The United States and Mexico . 
Albuquerque: University of New Mexico Press, 1978. 

Robinson L, Dabrowski A. Reaching to the South. 
U.S. News and Worid Report . March 1, 1993:43-46. 

Sanchez R. Health and enviroimiental risks of the 
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Report . 1989;3(3-5). 

Stoddard E. (Ed.). Border maquiladoras research and 
interpretation: An international symposium. Journal of 
Borderiands Studies . 1990; '5(1). 

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across the borders. Environumental Health Perspectives . 
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1992;13:8(418). 

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Press, 1993. 



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PESTICIDE PATCH TESTING: 

CALIFORNIA NURSERY 
WORKERS AND CONTROLS 

Michael O'Malley 

Department of Pesticide Regulation 

California Environmental Protection 

Agency, Sacramento, CA 

Pedro Rodriguez-H 

Hispanic Center of Excellence 

University of California, Davis 

Howard I. Maibach 

Department of Dermatology 

University of California, San Francisco 

ABSTRACT 

Nursery workers have been identified as a group at 
high risk for occupational skin disease among the 
subgroups of California agricultural workers. As a 
beginning attempt to define the portion of skin 
disease in this population due to allergic contact 
dermatitis, patch testing was performed on 21 
occupationally unexposed controls and 39 
occupationally exposed subjects. One additional 
subject was interviewed but did not complete patch 
testing and one underwent testing to chlorothalonil 
only. Materials tested were those reported most 
frequently as suspected causes of dermatitis in 
California nursery workers during 1982-89 and 
which were not available as patch tests from 
commercial sources. In addition, inorganic sulfur 
was tested because of its overall frequency as a 
reported source of skin disease in California 
agricultural workers. Two additional materials, 
dichloronitroaniline (DCNA) and 

pentachloronitrobenzene (PCNB), were also 
included because of their structural similarity to 
other nitrobenzene sensitizers. Two frequently 
reported compounds, dodemorph and metalaxyl, 
were not tested because no source of technical 
material could be identified. Glyphosate and 
propargite were felt to act principally as irritants 
and were therefore excluded. Reactions of control 
and exposed subjects for all 13 materials were 
compared and recorded. 



D\SCUSS\ON 

The Finn Chamber dosed with approximately 30 
microliters of test solution was applied to the upper 
back, secured with paper tape, and read at 2 and 4 
days. The ICDRG system was used for the 
readings. The confrols were negative except for 
chlorothalonil, which had 4?+ to + reading at 0.01% 
but was negative at 0.001%; one control subject 
who reacted to chlorothalonil also had a + reaction 
to sulfur at 1%. The occupationally exposed 
subjects were negative except for PCNB (2/39 
greater than or equal to a + reading); sulfur (5/39 
greater than or equal to a + reading; one additional 
subject had a ?+ reading and also had a + reaction to 
acephate at 1.0%); and chlorpyrifos (1/39 greater 
than or equal to a + reading). The differing 
frequency of reactions between the exposed and 
control subjects was not statistically significant for 
PCNB, sulfur, chlorpyrifos, or acephate by Fisher's 
two-tailed exact test. 

The biologic significance of these findings could not 
therefore be definitely determined. For PCNB, the 
observed reactions could represent de novo 
sensitization induced by the provocation procedure, 
akin to those reported for the PCNB structural 
analog dinitrochlorobenzene (DNCB). For 
chlorpyrifos and acephate, the most relevant 
previous work in animal studies showing that 
various organophosphate compounds are potent 
experimental sensitizers. 

The reactions to sulfur could represent a systematic 
variation in irritant response between exposed and 
confrol subjects, rather than true allergic reactions. 
Sulfur is associated with approximately 15% of all 
cases of suspected pesticide contact dermatitis in 
California, accounting for its reputation as a potent 
skin irritant. However, standard skin irritation 
studies for most agricultural formulations have 
shown just the opposite. Other work, using guinea 
pigs, has shown that a 25% concentration of 
wettable powder produces a ++ irritant reaction. In 
the same study, the guinea pig maximization test, 
conducted with a 5% topical concentration of sulfur, 
has shown that elemental sulfur is a moderately 
sfrong experimental allergen. Two case reports 
implicate elemental sulfur as a human contact 
allergen. Schneider reported two cases of contact 



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i 



allergy in patients who used modifications 
containing elemental sulfur to treat superficial 
fungal dermatoses. Both patients had positive 
patch-test reactions to 5% elemental sulfur in 
various vehicles. A control series was not reported. 
Wilkinson reported the case of a professional 
gardener, with a previous history of atopic eczema, 
who developed an eczematous eruption involving 
the elbow flexures and the right hand. He had a 
positive patch-test reaction to 5% sulfur in 
petrolatum, but a control series was not reported. 

Gregorczyk and Swieboda described 15 cases of 
desquamative dermatitis among 425 Polish sulfur 
miners in which irritant contact dermatitis due to 
elemental sulfur may have played a part. Our 
results and prior reports of allergy resulting from 
sulfur indicate that further studies on the effects of 
sulfur in other agricultural populations are 
warranted. 

Background 

Prior work on dermatitis in nursery workers 

>> Evaluation of the distribution of lost-work-time 
claims for skin disease in California agricultural 
workers has shown that nursery workers are among 
the highest risk for dermatitis due to both plant 
material and agricultural chemicals. The 
percentage of cases related to allergic contact 
dermatitis either to nursery plants or agricultural 
chemicals is unknown. Clinical diagnosis of 
allergic contact dermatitis requires challenge testing 
with workplace agents suspected of causing allergic 
reactions. 

5=* A prerequisite of performing challenge testing is 
the availability of relevant patch-test antigens 
(allergy-producing substances) at concentrations 
that do not provoke irritant reactions. 
Commercially available patch-test antigens are 
available for only a handful of pesticides. The 
initial step in our evaluation of the frequency of 
reactions to individual pesticides was the 
identification of suitable test concentrations for the 
provocation tests. 

Groups at risk for occupational skin disease 

>* National data indicate agricultural workers at 
highest risk for skin disease. 

5=* Compensation claims data indicate nursery workers 
are at highest risk for skin disease among 
California's agricultural production and agricultural 
service Standard Industrial Classification. 



Methods 

Control group: 21 volunteer subjects tested at the 
University of California, San Francisco (UCSF) 
Department of Dermatology, April and May 1992; 
none of the volunteers employed in agricultural or 
nursery operations. 

Exposed group: 39 subjects currently or formerly 
employed in California nursery industry — 28 
participants were identified from workers' 
compensation claims for dermatitis, allergic 
conjunctivitis, and allergic rhinitis and 11 were 
coworkers of those identified from compensation 
claims. Testing in exposed subjects was conducted 
from June through November 1992 at seven sites 
scattered from Humboldt to San Diego counties. 



Table 1: Pesticides associated with skin disease in 


California nursery workers, 1982-89— Pesticide Illness 


Surveillance Program, California Department of 


Pesticide Regulation 




Pesticide 


1982-89 Nursery 
skin cases 


Acephate 


21 


Benomyl 


35 


Captan 


15 


Chlorothalonil 


10 


Chlorpyrifos 


7 


Diazinon 


8 


Dienochlor (pentac*) 


22 


Dithane 


9 


Dodemorph (milban®) 


6 


Fenbutatin-oxide 


13 


Fluvalinate 


6 


Glyphosate (roundup®) 


6 


Malathion 


7 


Maneb 


5 


Metalaxyl 


9 


PCNB (terrachlor®) 


2 


Permethrin 


8 


Propargite 


5 


Vinclozolin 


7 


Zineb 


7 



5* Test substances: Intemational Contact Dermatitis 
Group standard series of common environmental 
allergens, commercially available plant and 
pesticide antigens, and pesticides commonly 



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associated with nursery dermatitis formulated at the 
UCSF Department of Dermatology laboratory. 
Results are presented here for 13 pesticide 
formulations newly developed for this study. 



Table 2: Comparison of control subjects and exposed 
worker reactions to 13 pesticides* 


Test materials 


Control 


Exposed 


96-hour 
reading 


96-hour 
reading 


Acephate 


0/21 


1/39 


Chlorothalonil(0.01%) 


4/11 


not tested 


Chlorothalonil (0.001%) 


0/10 


0/40 


DCNA 
(dichloronitroaniline) 


0/21 


0/39 


Diazinon 


0/21 


0/39 


Dienochlor 


0/21 


0/39 


Chlorpyrifos 


0/21 


1/39 


Fenbutatin oxide (0.1%) 


0/21 


0/39 


Malathion (0.5%) 


0/21 


0/39 


Permethrin 


0/21 


0/39 


Fluvalinate 


0/21 


0/39 


Vinclozolin 


0/21 


0/39 


Pentachloronitrobenzene 


0/21 


2/39 


Inorganic sulfur 


1/21 


5/39 


* All tested diluted 1 % in butanol except as indicated 



Results and Discussion 

Principal findings of the study included a high 
frequency of irritant reactions to chlorothalonil 
(0.01% and 0.05%) in the control group. Final test 
concentration in the exposed subjects was 0.001%, 
a concentiation that produced no reaction in either 
exposed or contiol subjects. 
1/21 control subjects showed a 1+ or greater 
reaction to sulfur compared to 5/39 exposed 
subjects. The increased frequency of reaction to 
sulfiir in the exposed subjects was not statistically 
significant. It may have resulted from a systematic 
variation in irritant response or may have 



represented a true allergic response. Further work 
in other populations exposed to sulfur is indicated 
because sulfur has accounted historically for 
approximately 15% of all cases of pesticide- 
associated dermatitis in California. 

Patch-test procedure 

>* The patch test is a bioassay to evaluate the presence 
or absence of delayed hypersensitivity to a given 
test compound or test substance. 

> Standard patch tests employ a small volume of the 
test substance (approximately 20-50 microliters) 
enclosed in an open 8 millimeter diameter 
aluminum chamber occluded against the skin of the 
upper back or dorsum of the upper arm for 48 
hours. Initial readings are made at the time the test 
is removed and final readings are made at 96 hours. 

>* Scoring is based on an international code system. 

• l=weak (nonvesicular) reaction: erythema, 
infiltration, papules (+) 

• 2=strong (edematous or vesicular) reaction (+ 

+) 

• 3=extreme (spreading, bullous, ulcerative) 

• 4=doubtful reaction, macular erythema only 

(?) 

• 5=irritant reaction (R) 

• 6=negative reaction 

• 7=excited skin 

• 8=not tested 

Possible Mechanisms of Action for Sulfur on the 
Skin 

What explains variable response to skin exposure? 
>► Possible transformations of elemental sulfur on the 
skin. 

> Production of irritants— transformation to sulfiir 
oxides to produce dilute acids on the skin. 

>* Production of allergens— transformation to sulfites, 
known to cause immediate hypersensitivity reaction 
in susceptible individuals. 

What factors are associated with skin transformations 
of sulfur? 

>- Variations in physical activity, e.g. sweating, 
difference between control group in our study and 
exposed workers all engaged in physical labor. 

>* Variations in skin metabolism— e.g., apparent 
differences in skin metabolism of dienochlor 
observed in our study that produced 
hyperpigmentation in some individuals and no 
visible response in others. 



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REFERENCES 



Gregorczyk KL and Swieboda K. Uber den Einflu B Schneider HG. Schwefelallergie. Hautartz 29:340, 

von Schwefelverbindungen auf die Haut und auf die. 1 978 . 

Schleimhaute (on the effect of sulfur contact with the Wilkinson DS: Sulphur Sensitivity. Contact Dermatitis 

skin and mucous membranes). Polski tygognik 1:58, 1975. 
Lekarski 23:463-66, 1968 cited in Schneider. 



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1 



OCCUPATIONAL HEALTH AND 

SAFETY TRAINING FOR 

MAQUILADORA WORKERS 

ALONG THE U^-MEXICO 

BORDER 

Garrett Brown, M.P.H. 

Leonor Norona Dionne, M.S. 

Michele Gonzalez-Arroyo, M.P.H. 

Emily Merldeth, M.P.H. 

Maquiladora Health and Safety Support 

Network 

Berkeley, California 

ABSTRACT 

Mexican maquiladora (assembly plant) workers face 
a variety of workplace hazards in industrial plants 
along the U.S. -Mexico border. Two-thirds of these 
workers are women. Mexican community 
organizations, in collaboration with U.S. support 
groups, have provided vital health and safety 
training to maquiladora workers in an effort to 
increase their knowledge of health hazards and legal 
rights in the workplace. This paper focuses on the 
role of a multidisciplinary training team from the 
U.S. -based Maquiladora Health and Safety Support 
Network in providing worker activists with 
information about job site health and safety and 
with skills to effectively educate coworkers and to 
organize for better working conditions. Detailed 
descriptions of the training are provided, including 
how training has contributed to improvements in 
health and safety conditions in factories, how the 
training was organized, and key elements of the 
training model. 

The Maquiiadora Health and Safety Support 
Network 

The worker training project described in this paper 
was developed and implemented by members of the 
U.S.-based Maquiladora Health and Safety Support 
Network. The Network, founded in 1993, is a 
volunteer organization of over 200 occupational 
health and safety professionals. Network members 
include industrial hygienists, health educators, 



occupational medicine physicians, toxicologists, and 
others who provide pro bono or free technical 
assistance, training, and information to workers in 
the maquiladoras as they struggle to improve their 
working conditions. 

First, we will give a brief introduction to the 
background and context of the training, and then we 
will describe the project in more detail. 

The Maquiladora Industry 
Over 2,000 maquiladora plants along the border 
employ over half a million workers who assemble 
products and components for a variety of industries. 
These include electronics, auto parts, furniture, 
medical supplies, plastics, clothing, and virtually 
anything else that requires assembly, painting, or 
packaging. About one-fourth of all maquiladora 
plants are in Tijuana where we have focused the 
majority, although not all, of our training efforts to 
date. 

Working Conditions 

Working conditions in these plants often endanger 
both workers' health and their ability to meet basic 
needs for food, clothing, and shelter. These 
conditions include the following: 

> There is ample evidence of serious chemical, 
physical, ergonomic, and safety hazards in 
maquiladora plants. These will be discussed in 
more detail later. 

>- In addition, wages for maquiladora workers are 
notoriously low, typically between 130 and 250 
pesos per week. At the current exchange rate of 6 
pesos to the dollar, that amounts to between 20 and 
40 doUars per week. It is no surprise, then, that the 
purchasing power of certain U.S. workers is 15-18 
times higher than that of Mexicans working similar 
jobs. 

> Approximately two-thirds of maquiladora workers 
are women, most of them young women, and sexual 
harassment appears to be widespread. For example, 
a recent case involved a U.S. corporate executive 
who attended a company picnic for maquiladora 
workers in Tijuana and proceeded to force female 
employees to parade around in bathing suits while 
he videotaped and kissed them. Those women are 
currently suing him. 

> There are also numerous documented instances of 
illegal firings and blacklistings of workers who are 
outspoken and attempt to exercise their rights. 



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>► Perhaps most important is that the most effective 
means of winning health and safety protections for 
workers in the United States, namely participation 
in an active labor movement, is severely restricted 
for maquiladora workers. Workers who try to 
organize unions independent of the state-controlled 
labor federations frequently meet with intimidation 
and violence. 

Economic Crisis 

Although these were all serious issues affecting 
v^orking conditions prior to the most recent 
economic crisis, the devaluation of the peso and 
implementation of other austerity measures have 
resulted in plummeting wages and rising 
unemployment. As the ranks of the unemployed 
swell, maquiladora workers' ability to demand 
improvements in working conditions is weakened 
because they can be easily replaced. 

Health and Safety Hazards 

Various researchers and community organizations 
have documented the serious hazards prevalent in 
maquiladoras. These findings have been confirmed 
anecdotally by workers from Nuevo Laredo, Ciudad 
Acuna, Matamoros, Reynosa, Ciudad Juarez, 
Piedras Negras, and Tijuana who have participated 
in our trainings. 

>• Unguarded machinery is a serious safety hazard. 
>* Repetitive motion, a fast work pace, and poorly 

designed work enviroimients represent serious 

ergonomic hazards that have led to a variety of 

repetitive strain injuries. 
>* Noise is probably the most common physical 

hazard, although excessive heat and cold have also 

been mentioned by workers. 

Our training project focuses primarily on chemical 
hazards. The list of solvents, heavy metals, acids, 
caustic chemicals, paints, and varnishes used in 
maquiladora plants includes carcinogenic and other 
highly toxic substances. Many workers whom we 
have trained appear to suffer from the acute health 
effects of overexposure to these substances, opening 
up the possibility of serious reproductive and 
other chronic or long-term effects. 

CoLONiAS (Neighborhoods) 

These workplace exposures to chemicals are 
compounded by the fact that workers who live in 
marginal neighborhoods surrounding the plants are 



doubly exposed due to illegally dumped hazardous 
waste near their homes. We conducted a fraining 
session in one neighborhood in Tijuana in an arroyo 
below a maquiladora plant, where a stream of 
hazardous waste flowed directly into the plaza of 
the colonia. 

Collaboration 

The worker training project represents an ongoing 
collaboration between the Maquiladora Health and 
Safety Support Network, U.S. -based support groups, 
and Mexican community-based worker advocacy 
organizations. Our overall goal is to strengthen 
worker movements that are dedicated to improving 
working and living conditions along the border. We 
focus on training workers who are in someway- 
linked to local organizations so that the knowledge 
and skills gained during the fraining will contribute 
to the development of local leadership capacity and 
have an ongoing, multiplier effect after the fraining 
is over. Our work is also part of a broader effort by 
unions, citizen groups, and coalitions to support 
workers in Mexico and advocate for implementation 
of health and safety measures in the plants. 

Training Agenda 

Although we tailor each fraining session to the 
needs of the participants, a typical agenda covers 
identification of health and safety hazards, basic 
"barefoot" toxicology (that is, how chemicals get 
into the body and affect health), evaluation and 
confrol of chemical hazards, personal protective 
equipment, and Mexican health and safety law, 
including workers' legal rights. Each group we have 
worked with has also been given a set of Spanish- 
language material safety data sheets and other 
resources so that community organizations have a 
source to turn to for information on chemicals used 
in the workplace. 

Risk Maps 

We usually begin each fraining session with an 
exercise called risk mapping in order to identify the 
hazards present in each of the plants represented at 
a fraining. This technique was developed in Mexico 
and is now used in the United States in worker 
fraining. Workers draw a floor plan of their plant 
and then identify the physical, chemical, and other 
hazards in each area. Workers can quickly identify 
the hazards in their plants, the first step in 



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addressing workplace health and safety problems. 

After each group identifies the hazards in their 
plant, they report back to the entire group. 
Participants discuss and make connections about 
similar hazards and problems faced in common by 
many maquiladora workers. 

This exercise also lays the groundwork for the rest 
of the training, and we often refer back to the maps, 
for example, when brainstorming different methods 
of controlling hazards. 

Case Studies 

We use a series of case studies to teach workers how 
to investigate the routes of entry, symptoms, and 
adverse health effects associated with different 
chemicals in their workplaces. The participants are 
presented with scenarios describing a workplace 
health and safety situation and asked to use a variety 
of sources to find answers to specific questions 
about the chemicals or other hazards involved. 

They learn to read labels that are often in English 
and how to identify key words and warnings. They 
also learn to identify the different sections on a 
material safety data sheet and how to look up the 
information they need about different chemicals. 

Learning Games 

We also use learning games and "dinamicas" 
(dynamic situations) to teach different aspects of 
health and safety. Games are an effective and 
nonintimidating way to break the ice, involve 
people in the learning process, and introduce 
difficult concepts to a group. The learning games 
have been one of our most successful methods for 
teaching groups with limited literacy skills about 
health and safety on the job. 

Role Plays 

After reviewing Mexican health and safety 
standards and regulations, we ask the participants to 
develop role plays using their new knowledge of 
health and safety law as a basis for finding creative 
solutions to typical situations they encounter in 
their work. These often center around practicing 
how to approach the boss or supervisor with health 



and safety concerns, educate coworkers about 
hazards, or organize actions to effect change in the 
workplace. The emphasis is on finding tactics that 
enable them to assert their rights without 
jeopardizing their jobs. 

In a number of our training sessions, we also devote 
time to "training of trainers" activities where 
participants learn how to use these same techniques 
to teach their coworkers about hazards. 

Evaluation 

Each training session is evaluated by the 
participants verbally and on a written anonymous 
form. We use the evaluations to assess the extent to 
which the training met participants' needs and the 
effectiveness of our teaching strategies. 

To date, we have not done a formal impact 
evaluation of the training project. Anecdotally, we 
have heard of changes in plant working conditions 
that have come about due, at least in part, to actions 
taken by participants. For example, in three plants in 
Tijuana, workers anonymously placed written 
information on health and safety issues and Mexican 
regulations on their supervisors' desks. The 
following week, workers received gloves and other 
personal protective equipment, and in one plant a 
local exhaust ventilation system was installed. 

Many of the workers we have trained have 
continued to participate in local organizations and 
groups that advocate for worker rights. 

Future 

We plan to continue calling attention to hazardous 
working conditions in maquiladora plants. The 
Maquiladora Health and Safety Support Network 
will also continue to collaborate with professional 
and community organizations to provide training 
and technical assistance to those who are dedicated 
to improving the working conditions for 
maquiladora workers. We will also continue 
supporting independent organizing efforts. Our 
intention and hope is that these efforts contribute to 
an ongoing, broader worker movement for justice in 
the maquiladoras. 



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THE REPRODUCTIVE HEALTH 
AMONG WOMEN WORKERS IN 

THE MAQUILADORA 

INDUSTRIES IN TIJUANA, BAJA 

CALIFORNIA 

LA SALUD REPRODUCTIVA 

ENTRE MUJERES 

TRABAJADORAS DE LA 

INDUSTRIA MAOUILADORA EN 

TIJUANA, BAJA CALIFORNIA' 

Cristina von Glascoe, Ph.D., M.D. 

Gabriela Vazquez, M.A. 

El Colegio de la Frontera Norte 

Miguel Angel Gonzalez Block, Dr. Sci. 

Fundacion Mexicana para la Salud 

Sylvia Guendelman, Ph.D. 
Universidad de California Berkeley 

ABSTRACT 

The objective of this work is to identify health 
problems, especially those affecting the reproductive 
health of women, related to direct work in the 
cosmetic industry. An investigation was conducted 
according to a methodology of selection that 
corresponds to a probability sample of 900 
interviews, beginning with the random selection of 
households from a list of workers in the industry that 
was provided by the Mexican Institute of Social 
Security. The questionnaire contains different topics 
organized in 10 modules — the sociodemographic 
characteristics of the women and their households, 
their work history, chronic illnesses, accidents, 
pregnancy, birth control, evidence of cancer, 
evidence of sexually transmitted diseases, 
aggressions, and use of services. 

This study identifies the demographic, social, and 
occupational factors that influence the women's 
health, as well as the patterns of access to health 



' Proyecto financiado por la Fundacion Mexicana para la 
Salud-Camegie. 



services. The majority of the working women in the 
sample are young migrants with a maximum 
education of primary school completion. Although 
not all of them are married, most have maintained a 
relationship with a companion. Among the notable 
results was the existence of illnesses associated with 
the type of work the women perform, such as 
nervous alterations, allergies, deafness, gastric 
problems, problems with the skin, and tired 
eyesight, as well as accidents; likewise, there is 
evidence that many health problems are associated 
with their socioeconomic status. In this same way, 
results are presented on complications during 
pregnancy, the results of the pregnancy, sexually 
transmitted diseases, and cancer of the uterus. 

Resumen 

En este trabajo se presentan dos modelos 
alternatives para el analisis del ciclo de vida de la 
mujer joven mexicana; el primero relacionado con 
valores culturales mexicanos, y el otro como 
descripcion de la forma en la cual se desvia del 
modelo normative en la situacion de mujeres 
jovenes que migran a la frontera para frabajar en la 
industria maquiladora. Se analizan datos de una 
encuesta de trabajadoras llevada a cabo en Tijuana, 
Baja California, de la que se desprenden hipotesis 
sobre la migracion y la formacion familiar, 
fecundidad, conocimiento y uso de la 
anticoncepcion y conocimiento de enfermedades de 
fransmision sexual. Los hallazgos demuestran que 
las jovenes recien migradas se encuentran en 
desventaja en comparacion con las mas asimiladas, 
en cuanto a su menor conocimiento de metodos 
anticonceptivos, y menor conocimiento de 
prevencion de enfermedades de transmision sexual. 
En ese mismo sentido, fue posible observar que la 
educacion mejora los indices para las que tienen 
mas tiempo en Tijuana. 

HiSTORiAS De Vida 

Elizabeth vive en el sur de Mexico. Va a cumplir 15 
aiios, y sus papas le van a festejar con una 
ceremonia junto con una misa en la iglesia. A partir 
de esa fecha ya va a ser vista como senorita, lista 
para iniciar un noviazgo. El noviazgo es un arreglo 
formal que se hace enfre el novio y el padre de la 
sefiorita; normalmente los novios salen 
acompanados por algun familiar. El noviazgo puede 



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durar poco o mucho, desde algimos meses hasta 
muchos anos, dando lugar a la posibilidad de que 
estudie una carrera antes de casarse. Conforme vaya 
evolucionando la relacion, el novio puede acudir al 
padre de la novia para pedirle permiso para que se 
casen. Al casarse se forma una nueva unidad 
domestica y se inicia una vida sexual activa con la 
probabilidad de que se embarace. 

Maria vive tambien en el sur de Mexico y va a 
cumplir 15 aiios, pero su situacion es distinta. 
Aunque puede ser que le festejen sus 15 afios, es 
probable de que ella vaya a querer desligarse de su 
familia; tal vez logre inscribirse en algiin trabajo 
domestico en su misma comunidad o en un centro 
urbano cercano. Quiza se entere de que hay 
posibilidades de empleo con buena remuneracion en 
la frontera y se vaya. Pero como se queda 
desprotegida en el sentido de estar sola sin familia y 
sin alguien que la cuide, tiene que buscar con quien 
vivir, y ese puede ser un muchacho que conocio por 
casualidad o quiza en el trabajo. Es probable que se 
embarace y que, antes o despues, entre en union 
libre con el muchacho. En este mismo escenario se 
mueven otras 25,000 mujeres que se encuentran en 
las mismas condiciones. 

MoDELOS De Desarrollo Familiar Y Del Migrante 
Trabajador 

Las mujeres jovenes han sido sefialadas por el 
modelo maquilador de desarrollo como una de las 
principales fuentes de riqueza de Mexico, 
especialmente a lo largo de la frontera Mexico- 
Estados Unidos. Este modelo ha motivado enormes 
cambios en la estructura sociodemografica de la 
poblacion, principalmente por medio de la migracion 
y el cambio de actividades de las mujeres, siendo que 
las mujeres jovenes forman el 60% de la frierza de 
trabajo maquilador. Pero ^que significa esto para la 
vida de uno? i,Que efecto tiene esta biisqueda de 
autonomia y el mejoramiento de las expectativas? 
^Cuales son las consecuencias? 

La cultura Mexicana tradicional ofrece la familia y la 
iglesia como amortiguadores para la transicion 
femenina de nina a adolescente y a mujer. Este 
sistema se caracteriza por una serie de pasos en 
donde la niiia experimenta un rito de pasaje a la edad 
de 15 anos, que anuncia su entrada a la edad adulta, 
y la posibilidad de seguir con el proximo paso que es 



el noviazgo. Esta etapa a su vez esta mediada por 
una negociacion formal entre el novio y los papas 
de la novia. La pareja solo sale acompanada por 
miembros de la familia de ella, siendo un hermano 
o una hermanita. En la proxima etapa el novio pide 
permiso al padre para casarse con su hija, y se fija 
una fecha para la boda. Se puede esquematizar este 
modelo de la situacion ideal como se muestra en la 
Figura 1. Ahi se incluye la posibilidad de que la 
seiiorita mantenga su virginidad, lo cual hace que 
los hombres acudan a prostitutas. Siendo el caso, la 
seiiorita no tendra experiencia con la planificacion 
familiar sino hasta despues de que se case, y en 
muchos casos hasta despues de tener su primer 
bebe. 

Figura 1 . Esquema Del Desarrollo Del Ciclo 
De Vida Reproductiva Ideal 



tKdadDomestica#l 



Raoxierte 



Hja 



IfariBno 



Boda en Iglesia 

(famaciande 
liiidadDDnKtica#2) 



I^esia 
(baudxi^ ccnfimBddn, 
quinceanaa, boda) 



Servido de prostitudcn 

(gilta de vida sexual activa de la 
seftxitadela&rilia) 




Este escenario ideal se aplica en una forma 
modificada aun en la frontera enfre miembros de la 
clase media urbana. Queda imprecisa la extension a 
la cual se aplica este modelo a la clase obrera. Sin 
embargo, lo postulamos como lo ideal en la cultura 
mexicana urbana contemporanea. Cuando la j oven 
senorita migra a la frontera se rompe este sistema 
amortiguador, puesto que muchas veces la familia 
se queda afras. La obrera migrante enfrenta dos 
fiientes de riesgo para su transicion segura a la edad 
adulta: se encuentra sin miembros familiares y lejos 
de su hogar, y ademas en una situacion de trabajo 
que la expone a hombres. La carga de protegerla se 
pasa de la familia y la iglesia a la industria y el 
sistema de salud. Esto corresponde a un cambio de 
enfoque de la calidad de vida a la calidad de 



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atencion, que es mas lejana y sin compromiso 
personal. Se puede esquematizar la transicion a 
adulta de la senorita obrera como se ve en la Figura 
2. 

Figura 2. Esquema Del Desarrollo Del Oclo De 
ViDA Reproductiva De Una Senorita De La Clase 
Obrera 



Fbrmarioncfe 
irii(bddDni&tica#2 
(mion h"bre) 




Cbrrpaifcros 

(vi(b sexual activa 

-y- planificadon fiimiliar) 




Encuesta Sobre La Salud Reproductiva 

Hicimos una valoracion de la salud reproductiva de 
las Trabajadoras de la Industria Maquiladora (TIMs). 
Entre los objetivos planteados, queriamos ver la 
manera en la cual la sexualidad de la mujer 
trabajadora, y el hecho de tener hijos, inciden en su 
calidad de vida. Se realize una encuesta para 
establecer las necesidades de salud reproductiva de 
las TIMs en las siguientes areas: 
> Oferta y utilizacion de servicios de salud 
reproductiva, particularmente de anticonceptivos, 
atencion prenatal y del posparto, prueba del cancer, 
enfermedades de transmision sexual y atencion 
preventiva, asi como ante la presencia de 
enfermedades cronicas y accidentes en el trabajo; 
>- Barreras culturales, geograficas, organizacionales y 
economicas para la utilizacion de servicios de salud 
reproductiva y atencion preventiva; 
>- Situacion de indicadores de salud reproductiva, 
incluyendo el comportamiento sexual. 

Como parte contextual se establecio un modulo de 
preguntas sociodemograficas y otro sobre la carrera 
laboral de la mujer. 

El tercer objetivo listado nos permite acercamos a la 
perspectiva de analisis que se aborda en este 
documento, ya que tomamos como variables 



dependientes aquellos indicadores referidos a la 
salud reproductiva de las TIMs, como son el 
conocimiento y la utilizacion de metodos, 
conocimiento y prevencion de enfermedades de 
transmision sexual y prevencion del cancer 
intrauterino. Estos indicadores los relacionamos con 
caracteristicas sociodemograficas como son la etapa 
del ciclo de vida en que se encuentran, su condicion 
migratoria, escolaridad y formacion familiar. 

Seleccion De La Muestra 

La poblacion bajo estudio corresponde a mujeres 
obreras en la industria maquiladora residentes en la 
Ciudad de Tijuana. Para lograr contar con una 
muestra representativa de esta poblacion se llevo a 
cabo una encuesta de hogares en poblacion abierta, 
con un tamaiio de muestra de 928 mujeres^. 

Debido a que la localizacion de los hogares de las 
TIMs resulta dificil, ya que sus domicilios se 
encuentran disperses por toda la ciudad, en un 
esquema de muestreo tradicional se requiere de un 
tamano de muestra muy grande de unidades de 
seleccion que garantice un numero minimo de 
TIMs; por ello se decidio que el disefio de la 
muestra partiera de un listado de trabajadoras 
adscritas al Seguro Social (IMSS) a principios de 
1995, el cual fue proporcionado por la misma 
institucion. A partir de este listado se seleccionaron 
al azar 150 domicilios y se asociaron a una 
manzana^. La manzana fiie censada y se 
entrevistaron a todas las mujeres que cumplieran 
con el requisite de trabajar en la maquiladora en la 
linea de produccion directa, aun cuando no 
estuvieran laborando (licencia, vacaciones etc.). 
Este diseiio, parte del supuesto de que la 
probabilidad de encontrar una mujer trabajadora de 
la industria maquiladora en una manzana 
preseleccionada por la presencia de una TIM es 
mayor que si se seleccionara a partir de un muestreo 
con una estratificacion socioeconomica del espacio. 



^ Los 928 casos son el numero de entrevistas levantadas una 
vez que se eliminaron las entrevistas incompletas. 

' Cabe aclarar que el listado no diferenciaba el puesto de 
trabajo de las mujeres por lo que dentro de la seleccion de la 
muestra quedaron domicilios de mujeres en cargos 
administrativos o de direccion. 



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Perspectiva DeAnausis 

Para abordar el problema que nos ocupa, se necesita 
de un entendimiento de las presiones y areas de 
eleccion disponibles para la trabajadora joven recien 
llegada a la frontera. Para hacer esto hacemos una 
interpretacion de los datos segun los modelos 
culturales arriba presentados. Utilizamos la encuesta 
como el instrumento principal, y agregamos 
conocimiento clinico y cultural, que nos permiten el 
planteamiento de las hipotesis de trabajo. 

El analisis de los resultados se respalda a traves del 
uso de medidas de asociacion estadistica, como son 
el valor-p de la x^ y el coeficiente de incertidumbre 
con su nivel de significancia. 

Para ver el efecto de la migracion sobre el estilo y 
calidad de vida, se dividio a la poblacion en dos 
partes: aquellas que tienen menos de 5 anos en 
Tijuana, y las que tienen 5 6 mas (dentro de este 
grupo se incluyen a las nacidas en Tijuana)". Para 
controlar la etapa de ciclo de vida elegimos a la 
poblacion bajo estudio como aquella que inicia su 
etapa reproductiva hasta alcanzar los 25 afios^ La 
premisa para restringir a la poblacion bajo estudio era 
contar con un grupo mas homogeneo respecto a la 
etapa reproductiva en la que se encuentra la mujer, 
que se traduzca en indicador del comportamiento de 
su salud reproductiva como son la fecundidad, la 
anticoncepcion, y las enfermedades de transmision 
sexual, bajo el supuesto de que a mayor edad mayor 
sera el entendimiento sobre su salud reproductiva. 

La pregunta central que se planteo fue como afecta la 
condicion de migrante reciente en la formacion 
familiar, la fecundidad, el conocimiento y uso de la 
anticoncepcion y el conocimiento de las 
enfermedades de transmision sexual, teniendo en 
cuenta su nivel de escolaridad y estado civil. 

Antes de contestar las preguntas que centran este 
trabajo, describiremos brevemente las caracteristicas 



de las mujeres obreras jovenes de la industria 
maquiladora de Tijuana. 

CuADRO 1 . Caracteristicas De La Poblacion 
Bajo Estudio (Estimaciones de la Muestra) 



* El hecho de sefialar 5 alios resulta de un estudio de 
Guendelman et al. (American Journal of Epidemiology (1995) 
142; S30-S38) que mostro este corte como el umbral de 
aculturacion entre mujeres migrantes a California en cuanto con 
su conducta relacionada con la salud. 

' La submuestra correspondiente a las mujeres de menos de 25 
aAos es de 464 casos. 



Tamano de muestra 


928 




baza 


Media 


26.5 


Mediana 


25 






Nacidas fuera de Tijuana 


81.8% 


<5 afios de residencia 


37.5% 




Edad a la que arriban a Tijuana 


Media 


19.1 




Edad a la que inician su etapa laboral 


Edad media al ler empleo 


9.2 


Edad media ler empleo maquila 


21.2 




Escolaridad 




Mayor a primaria 


54.3% 


Estado civil 


Solteras 


38.4% 


En pareja 


46.7% 


En union libre 


44.8% 


Separacion 


15.0% 


Fecundidad 


Promedio de HNV 


1.7 


Ha tenido hijos 


58.1% 



Caracterizacion De La Poblacion Bajo Estudio 

Las mujeres obreras de la maquiladora se 
caracterizan por ser jovenes (26.5 afios en promedio, 
y el 50% menor a los 25 afios), en su mayoria 
corresponden a migrantes (81.8% nacidas fliera de 
Tijuana) con poco tiempo de residencia (37.5%) 
Uegaron hace menos de 5 afios). Entre las migrantes, 
la edad a la que arriban a Tijuana es a una etapa 
temprana de su ciclo reproductivo 19.1 afios y que 
coincide con la edad a la que inician su etapa laboral 



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(19.3 afios al primer empleo y a los 21.2 anos su 
primer empleo en la maquiladora). Se caracterizan 
por una educacion que supera ligeramente la primaria 
terminada (el 54.3% cuenta con algiin ano de estudio 
de secundaria o equivalente). El inicio de la 
actividad laboral se da con anterioridad a la 
formacion de la pareja, asi encontramos que el 38.4% 
de las mujeres obreras se encuentran solteras, otra 
situacion comun es que si bien encontramos que el 
46.7% se encuentra viviendo en pareja, el 44.8 de 
ellas vive en union libre; el resto de las mujeres ha 
experimentado una disolucion (15%, ya sea por 
separacion, divorcio, viudez). En relacion a su 
fecundidad, el promedio de hijos nacidos vivos es de 
1.67, el 41.9% no ha tenido hijos. 

Tims Jovenes (Menores De 25 Anos) 

Cerca de la mitad tiene menos de 5 anos de residir en 
Tijuana (48.9%)). El 60.6% de ellas cuentan con 
algiin grado mas alia de la primaria. El 60.6%) son 
solteras, el 17.7% viven en union libre y el 14.7% 
estan casadas, para el 7.1% su union ha si do disuelta 
ya sea a traves de la separacion, divorcio o viudez. El 
31.3% ha tenido al menos un hijo. Este hecho nos 
lleva a pensar que la union esta influenciada por 
tener un hijo (o haberse embarazado). 

En cuanto a su experiencia laboral, el 50.9%) de las 
migrantes, antes de llegar a Tijuana ya habian 
trabajado. Para el 13.9% de las obreras, su primer 
empleo fue en la maquiladora, siendo la industria 
electronica la que acapara la mayor parte de las 
mujeres jovenes que se insertan en la industria 
maquiladora, 54.2%); actualmente, el 58.0%) trabaja 
en la industria electronica. 

Hipotesis 

>■ Las migrantes recientes no viven dentro del nucleo 
familiar a menos que formen uno nuevo a partir de la 
union. 

El cuadro 1 permite observar que entre la poblacion 
con 5 afios y mas de residencia en Tijuana es mas 
comun vivir dentro del hogar patemo, este o no la 
mujer en union (4.89%, para las alguna vez unidas y 
17.3% para las nunca unidas cuando son migrantes 
recientes en contraste con el 10.17% y 55.08%) para 
las alguna vez unidas y las nunca unidas 
respectivamente cuando han vivido mas de 5 afios en 



Tijuana)*. 

En contraste, cohabitan en otro hogar con mayor 
frecuencia si la mujer es migrante reciente; la unica 
manera de contar con su propio hogar es a partir de 
la union (27.11% viven en hogar propio y se 
encuentran unidas para las migrantes recientes en 
comparacion con 17.37% para las que han vivido 
mas de 5 anos en Tijuana). 

>* Hay una manor formalizacion de la union entre las 
migrantes recientes^. 

La idea que sostenia dicha hipotesis consiste en que 
si bien la tradicion del matrimonio continiia, no 
obstante la separacion de la unidad domestica 
patema, se afiadiria un covalente mas alto de 
cohabitacion. Es decir, existe una urgencia para 
formar la unidad domestica dada la ausencia del 
nucleo familiar natal. 

Los resultados muestran que el 57.7% de las recien 
migradas unidas viven en union libre, mientras que 
50.0% de las no recien migradas viven asi. No 
obstante, el porcentaje de cohabitacion es mayor 
entre las recien migradas; no existe una asociacion 
estadistica significativa entre la condicion 
migratoria y la formalizacion de la union (valor-p = 
0.348). 
>" Para las TIMs con menor escolaridad, es mas 

comiin la cohabitacion sin formalizar la union entre 

las migrantes recientes. 

No se encontro asociacion entre la condicion 
migratoria y la formalizacion de la union para las 
mujeres con menor escolaridad (valor-p = 0.264). 
>- Entre las migrantes recientes, a mayor escolaridad 
tienden a permanecer solteras a diferencia de 
aquellas con menor escolaridad (valor-p= 0.139) 

No se encontro una asociacion para las migrantes 
recientes, sin embargo, la escolaridad tiene un 
efecto entre las mujeres con mayor tiempo de 



* Definimos hogar patemo, como aquella mujer que cohabita 
dentro de un hogar cuyo jefe sea su padre o madre, hogar 
propio, cuando ella o su companero son los jefes del hogar; y 
otro hogar, cuando el jefe es algun otro pariente o una persona 
sin parentesco. 

' No se presenta el cuadro, en el caso de no encontrar una 
asociaci6n estadistica. 



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residencia en Tijuana, vease el cuadro 3. Es decir, las 
mujeres con mayor escolaridad tienden a permanecer 
solteras cuando tienen mas de cinco anos de 
residencia en Tijuana (valor-p=0.057). 
>* Hay una mayor posibilidad de que las migrantes 

recientes tengan un hijo si no estan apoyadas por el 

niicleo familiar natal. 

Esta hipotesis no se comprobo, al no e'ncontrarse una 
asociacion entre la condicion migratoria y la experiencia 
de tener al menos un hijo (valor-p=0.539), incluso al 
controlar por estado civil (niinca unidas: 0.112 y alguna 



vez unidas: 0.4009). Asimismo se obtuvo el promedio de 

hijos por mujer, no encontrandose una diferencia 

significativa (nunca unidas: 0.06 y 0.12 hijos por mujer 

para mujeres con menos de 5 anos y 5 y mas anos, con un 

valor-p= 0.135; y 0.95 y 1.12 hijos por mujer para las 

alguna vez unidas, con un valor-p= 0.199). 

>► Las migrantes recientes cuentan con menor 

conocimiento de planificacion famihar y por lo 

tanto la utilizacion de metodos es menos frecuente 

que entre las mujeres con mayor tiempo de residir 

en Tijuana. 



Cuadro 2. Mujeres Por Categoria Migratoria Y Estructura Del Hogar 







Hogar propio, 


Otrohogar, 

Alguna Vez 

XJnida 


/^*««-v: ■■■■:■ ■■•:':--i-: 


;<:W:Wff-<-^-<:::f:<:W::-<:<----<<<y-: 


Hogar 


Cond. 




otro 


Hogar 


hogar, 


paterno, 


paterno, 


migratoria 


Total 




Nunca 


Alguna Vez 


Nunca 


Alguna vez uniua 










Unida 


Unida 


Unida 


Frecuencia 


<5 afios 


225 


61 


32 


82 


11 


39 


5 + aflos 


236 


41 


14 


27 


24 


130 


Distribucion relativa (%) 


< 5 afios 


100 


27.11 


14.22 


36.44 


4.89 


17.33 


5 + afios 


100 


17.37 


5.93 


11.44 


10.17 


55.08 



Valor - p= 0.000 (x2) 
Coef. Incert. =0.07 valor- p= 0.000 



Cuadro 3. Mujeres Con 5 6 Mas Anos De 
Residir En Tijuana Por Nivel De Escolaridad Y 
Estado Civil 



Escolaridad 


Total 


Nunea 
unidas 


Alguna 
vez unidas 


Frecuencia 


Primaria o menos 


88 


52 


36 


Mis de primaria 


149 


106 


43 


Distribucion relativa I 


% Primaria o 
menos 


100.0 


59.1 


40.9 


% Mayor a 
primaria 


100.0 


71.1 


28.9 



Valor-p = 0.057 (x2) 
Coef inc.: 0.01185 valor-p: 0.05864 



En el cuadro 4 se puede observar que si existe 
una asociacion entre la condicion migratoria y el 
conocimiento de metodos anticonceptivos 
(valor-p= 0.0015). Asimismo, se controlo dicha 
asociacion por estado civil (nunca unidas y 
alguna vez unidas) y se encontro que para 
ambos grupos persiste la asociacion entre la 
condicion migratoria y el conocimiento de 
metodos^ Es decir, las mujeres migrantes 
recientes se encuentran en desventaja sobre el 
conocimiento de los metodos anticonceptivos. 
Un analisis posterior por tipo de metodo nos 
permitio corroborar dicha hipotesis (dichos 
resultados no se presentan en este trabajo). 



Q 

Se definio como conocimiento de metodos 
anticonceptivos la identificacion verbal de los nombres sin 
que estos fueran listados, sin que se les preguntara sobre la 
forma de uso. Para fines de este trabajo, se dividio a las TIMs 
de acuerdo con el numero de metodos que conocian. 



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En cuanto al uso de metodos anticonceptivos, se 
puede observar en el cuadro 5 que existe una baja 
asociacion entre la condicion migratoria y la 
practica, medida esta a traves del indicador del uso 
de metodos alguna vez en su vida. Tambien se 
midio respecto al uso actual de metodos (en el 
ultimo ano), no encontrandose asociacion. Al igual 
que con el conocimiento de metodos, se control© 
con el estado civil, observandose que dicha 
asociacion es espurea, es decir, no existe una 
asociacion directa sino que el estado civil explica la 



relacion entre la condicion migratoria y el uso de 

metodos anticonceptivos. 

5^ A mayor escolaridad, mayor conocimiento y 

utilizacion de planificacion familiar entre las 

migrantes recientes. 

Se encontro que existe una asociacion entre la 
escolaridad y el conocimiento de metodos 
anticonceptivos, que implica que a mayor 
escolaridad mayor es el conocimiento (valor- 
p=0.00023), vease cuadro 6. Se revise la asociacion 



Cuadro 4. Mujeres Por Estado Civil Y Condicion Migratoria Segun Su Conocimiento De 
Metodos Anticonceptivos 



Estado civil/ 
condicion 
migratoria 


Frecuencia 


Distribucion porcentual 


Total 


No conoce 

algun 

metodo 


Solo un 
metodo 


Mas de un 
metodo 


No conoce 

algun 

metodo 


% Solo un 
metodo 


% Mas de 
un metodo 


Total 


Valor-P = 0.0015 (x2) 


Coef inc.=0.0219 Valor-P: 0.005 


<5 anos 


227 


31 


25 


171 


13.7 


11 


75.3 


5 + anos 


237 


10 


26 


201 


4.2 


11 


84.8 




Nunca Unida 


Valor-P = 0.0053 (x2) 


Coefinc.= 0.0267 Valor-P: 0.005 


<5 anos 


123 


22 


15 


86 


17.9 


12.2 


69.9 


5 + anos 


158 


9 


22 


127 


5.7 


13.9 


80.4 




Alguna vez 
unida 


Valor-P = 0.0015 (x2) 


Coef. inc.= 0.022 Valor-P: 0.005 


<5 anos 


104 


9 


10 


85 


8.7 


9.6 


81.7 


5 + anos 


79 


1 


4 


74 


1.3 


5.1 


93.7 



entre escolaridad y conocimiento, para cada uno de 
los grupos segun la condicion migratoria, 
observandose que para el grupo de migrantes 
recientes, la escolaridad tiene un efecto sobre el 
conocimiento de los metodos (valor-p= 0.00024), no 
asi para las mujeres con mayor tiempo de residir en 
Tijuana (valor-p=0.561 1). 

En cuanto a la utilizacion de metodos (ya sea alguna 
vez en su vida o durante el ultimo ano) no se 



encontro una asociacion entre la escolaridad y la 
utilizacion, para el conjunto de la poblacion y para 
cada uno de los grupos migratorios. 

>► Menor conocimiento de ETS entre las migrantes 
recientes. 

Se comprobo dicha hipotesis, poniendo en 
desventaja a aquellas con menos de 5 afios de 
residencia. 



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CUADRO 5. MUJERES POR CONDICION MiGRAJORIA SEGUN ESTADO CIVIL Y UTIUZAOON DE LA PRACTICA 

Anticonceptiva (Alguna Vez En Su Vida) 



Cond 
migratoria 


Total 


Nunca Unida 


Alguna Vez Unida 


Si 


NO 


Si 


NO 


Si 


NO 


Frecuencia 


<5 aflos 


73 


44 


3 


11 


70 


33 


5 + afios 


74 


25 


9 


11 


65 


14 


Distribucion relativa 


<5 aflos 


62.4 


37.6 


21.4 


78.6 


68 


32 


5 + aflos 


74.7 


25.3 


45 


55 


82.3 


17.7 


Medidas de 
asociacion 


valor-p=0.0523 (x2) 
coef inc.:0.014 valor-p:0.05 


valor-p=0.1569(x2) 
coef inc.: 0.047 valor-p 0.1497 


valor-p=0.0287 (x2) 
coef inc.: 0.0236 valor-p:0.0266 



Cuadro 6. Mujeres Por Condicion Migratoria Y Escolaridad Segun Su Conoomiento De 
Metodos 



Cond migr 


Total 




^^ ^wirxc 




4-4- ^nttQ 












Conoc 

metodos/ 

Escolaridad 


No 

conoce 

algun 

metodo 


Conoce 
Solo un 
metodo 


Conoce 

mas de 

uno 


No 

conoce 

algun 

metodo 


Conoce 
Solo un 
metodo 


Conoce 

masde 

uno 


No 

conoce 

algun 

metodo 


Conoce 
Solo un 
metodo 


Conoce 

masde 

uno 


Frecuencia 


Primaria 
Incompleta 


27 


25 


131 


22 


14 


59 


5 


11 


72 


Algo de 
secundaria 


14 


26 


241 


9 


11 


112 


5 


15 


129 


Distribucion Relativa 


Primaria 
Incompleta 


15.0 


13.7 


71.6 


23.2 


14.7 


62.1 


5.7 


12.5 


81.8 


Cond migr 




Total 


<5 alios 




5+ anos 


Conoc 
metodos/ 
Escolaridad 


No 

conoce 

algun 

metodo 


Conoce 
Solo un 
metodo 


Conoce 

mas 
de uno 


No 

conoce 

algun 

metodo 


Conoce 
Solo un 
metodo 


Conoce 

masde 

uno 


No 
conoce 
alguun 
metodo 


Conoce 
Solo un 
metodo 


Conoce 

mas de 

uno 


Algo de 
secundaria 


5.0 


9.3 


85.8 


6.8 


8.3 


84.4 


3.4 


10.1 


86.6 


Medidas de 
asociaci6n 


Coef inc. :0 


valor-p= 0.00023 (x2) 
.0278 v-p: 0.00028 


valor-p= 0.00024 (x2) 
Coef inc: 0.0503 v-p: 0.00025 


Coef inc: 0. 


valor-p= 0.561 l(x2) 
0046 v-p: 0.5691 



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CUADRO 7. MUJERES POR C0NDI06n MlGRATORlA 
Segun Su CONOOMIENTO DE ETS 



Condicion 
migratoria 


No 
conoce 


Conoce solo 
VIH 


Conoce 
otras ETS 


Frecuencia 


< 5 aiios 


76 


100 


51 


5 + aiios 


44 


121 


72 


Distribucion Relativa 


<5 anos 


35.5 


44.1 


22.5 


5 + anos 


18.6 


51.1 


30.4 



valor-p: 0.00096 (x2) 
Coef inc.: 0.01432 valor-p: 0.0009 

CONCLUSIONES 

Los hallazgos de este estudio nos permiten 
generalizar que la TIM que ha migrado para trabajar 
en la frontera norte efectivamente pierde el apoyo 
de su familia natal, y nos muestra que la unica 
manera de contar con su propio hogar es a partir de 
la union, sea esta de manera formal (casada) o no 
(unida). Asi es que afirmamos que las migrantes 
recientes deben hacer uso de las redes sociales para 
su subsistencia, sin depender por ello de sus padres, 
por lo cual aumentan su autonomia residencial y 
pierden la proteccion que otorga vivir dentro de la 
unidad domestica patema. Por otra parte vemos que 
existe una asociacion entre la condicion migratoria 
y los indicadores de salud reproductiva matizados 
por el estado civil y la escolaridad de las TIMs. 

Entre dichos resultados se observa una asociacion 
entre la condicion migratoria y el conocimiento de 
metodos anticonceptivos (incluso si se controla por 
estado civil); poniendo a las migrantes recientes en 



desventaja sobre el conocimiento de los metodos 
anticonceptivos. Tambien se encontro que existe 
una asociacion entre la escolaridad y el 
conocimiento de metodos anticonceptivos, que 
implica que a mayor escolaridad mayor es el 
conocimiento. Ademas, se determino que para el 
grupo de migrantes recientes, la escolaridad tiene un 
efecto sobre el conocimiento de los metodos, no asi 
para las mujeres con mayor tiempo de residir en 
Tijuana. Finalmente, se comprobo que existe menor 
conocimiento de enfermedades de transmision 
sexual entre las migrantes recientes. 

No se probo la hipotesis referente a la menor 
formalizacion de la union entre las migrantes 
recientes por urgencia de formar una unidad 
domestica dada la ausencia del nucleo familiar 
natal. Tampoco se encontro asociacion entre la 
escolaridad y la formalizacion de la union, ni entre 
mayor escolaridad y el permanecer solteras entre las 
recien migradas (aunque las mujeres con mayor 
escolaridad tienden a permanecer solteras cuando 
tienen mas de cinco aiios de residencia en Tijuana). 
Por ultimo, no se vio mayor posibilidad de que las 
migrantes recientes tengan al menos un hijo, a 
diferencia de las que han vivido mas de cinco anos 
en la frontera. Es decir, no obstante que las 
categorias analizadas tienen un efecto sobre los 
indicadores de salud reproductiva (sobre todo en 
relacion a su conocimiento), dicha situacion no 
trasciende en las decisiones del ambito familiar, 
como son la decision de formar una pareja, el 
numero de hijos e incluso la utilizacion de metodos 
anticonceptivos. 



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INNOVATIVE STRATEGIES IN 

DELIVERING HEALTH CARE: 

THE PROMOrORA MODEL 

Maria Gomez-Murphy, M.A. 

Director of Health Promotion/Disease 

Prevention and Primary Care Research 

Mariposa Community Health Center 

Santa Cruz County, Arizona 

ABSTRACT 

Promotora or lay health worker (LHW) models are 
effective bridges between the traditional health care 
system and low-income populations who have 
difficulty accessing the system. Most promotora 
models work within the open system of a 
community, addressing many types of health 
problems, and working with many types of people. 
A promotora works within her clients' cultural and 
psychosocial context. She is a member of the target 
community and reaches her clients through 
nontraditional means. She is trained in specific and 
general health topics, but cannot give medical 
advice. The promotora partners with the targeted 
population to access quality health care for low- 
income clients. The program also has an impact on 
the LHW, creating a spiral effect of personal and 
community empowerment. As the promotora helps 
others, she helps herself. 

Promotora Models 

Promotora models have a precedent in Third World 
countries, where health care personnel and resources 
are scarce, and have worked successfully in the 
United States since the 1950's. Two examples of 
U.S. programs are the Navajo Community Health 
Representatives and the Migrant Farm Worker 
Outreach Programs of the 1950's and 1960's, 
respectively. 

Most promotora models work within the 
sociocultural, ideological, and environmental 
systems of a community and address not only a 
multitude of health problems but also a diversity of 
people. The promotora is a member of the target 
community and reaches her clients in nontraditional 



locations, such as factories, homes, laundromats, 
and outside churches and shopping malls, and 
through nontraditional means, such as pldticas or 
health chats. She is trained in general and specific 
health topics but cannot diagnose or give medical 
advice. Instead, the promotora partners with the 
targeted population to access health care. 

PlATICAMOS SALUD 

The Office of Health Promotion/Disease Prevention, 
also known as Platicamos Salud (Let's Talk Health), 
of the Mariposa Community Health Center uses a 
lay health worker or promotora model to serve the 
uninsured and underinsured population of Santa 
Cruz County, Arizona. Nogales, the largest city and 
county seat, sits on the U.S.-Mexico border. The 
city has a population of 20,000, with a total 
population of 30,000 throughout the rest of the 
mostly rural county. Per capita income is slightly 
more than $9,000, resulting in almost 60% of the 
population living below 200% of the Federal 
poverty guidelines. Nogales is a federally 
designated medically underserved area, as well as a 
health professional shortage area. 

In this context, the definition of the word "health" 
used by Platicamos Salud parallels that of the 
World Health Organization— that is, a state of 
complete physical, mental, and social well-being, 
not merely the absence of disease or infirmity. 

Some of the barriers to health care that Santa Cruz 
County inhabitants experience are cost of care, lack 
of transportation, illiteracy, language, low 
educational levels, lack of knowledge of available 
community resources, and past negative experiences 
with the health care system. 

Promotoras are able to help clients overcome these 
barriers because of intensive educational training 
that emphasizes the importance of practice and 
review. This training covers a variety of health 
topics as well as support skills such as active 
listening, decision making, problem solving, and 
stress management. Emphasis is placed on the 
referral process — knowing where community 
resources are and how to access them. Training is 
didactic and experiential. It is also concrete and 
abstract. The promotora learns specific intervention 



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methods and the identification of the context in 
which the need for intervention exists. 

What do we look for in a promotoral In 
recruitment we look for evidence of natural 
leadership, the ability to accept responsibility, the 
desire to help others, knowledge or use of 
community resources, and a commitment to 
maintain confidentiality, which is important in a 
small rural community. Many of our promotoras 
have firsthand knowledge of poverty and have been 
or still are on some form of public assistance. Thus, 
natural empathy is developed with the client. 

In selecting a promotora from this socioeconomic 
milieu you accept many of the clients' problems into 
your program. These could be difficulty with life 
planning— an external locus; poor work habits (a 
different concept of time, working with schedules or 
deadlines); learned helplessness; an 

overidentification with failure; and fatalism. One of 
the problems that sometimes emerges in promotora 
programs is that the training to overcome these non- 
life-enhancing behaviors can create a distance 
between the client and the newly trained promo/ora. 
However, if the promotora overidentifies with the 
problems of her clients and the community, she may 
feel a need to criticize the hiring agency's objectives 
and methodologies and come in conflict with that 
agency. The key to a successful promotora is 
seeking a balance between these opposing forces. 
Nonetheless, the results of training and subsequent 
mentoring of clients in effective life planning and 
health behaviors create a spiral effect of personal 
and community empowerment. As the promotora 
helps others, she helps herself. 

Why is the promotora model effective? Research 
indicates that Hispanics rarely turn to health care 
professionals for health-related information but 
instead seek out peers or authority figures within 
their own social networks. In the case of childbirth, 
for instance, women rely on the advice of their 
mothers, grandmothers, and tias ("aunts") in lieu of 
health care providers. Many of these clients have 
little understanding of American "high-tech" 
medicine. Their experience with health often 
includes magical and/or supernatural components. 
Illness is perceived as mysterious and subject to 



otherworldly intervention. Therefore, effective 
delivery of health information begins with 
emotional and psychological methods such as 
establishing rapport with the client, becoming a 
comadre (godmother), a friend, a health partner. 

Presently, in the Platicamos Salud office, we have 
five major programs running concurrently. The first 
is Health Start or Comienzo Sano funded by the 
Arizona Department of Health Services. It uses 
home visiting as its vehicle for delivering health 
information to women who wouldn't normally have 
access to such information. The program goals and 
objectives are to: 

>* Reduce the incidence of low birthweight babies and 

childhood diseases; 
>* Increase prenatal services and immunizations by the 

age of 2; and 
> Educate families on developmental disabilities, 

school readiness programs, and the benefits of 

preventive health care and screening examinations 

such as for hearing and vision. 

Th& promotora works with her client as soon as the 
client knows she's pregnant. Home visits take place 
once a month during the pregnancy and 13 times 
after the birth of the baby. These postpartum visits 
follow the immunization schedule for children up to 
the age of 4. 

The second program involves a cadre of volunteer 
patient facilitators coordinated by one of our 
promotoras. The program's purpose is to help 
patients enter and effectively utilize the health care 
delivery system of the Mariposa Community Health 
Center. Volunteers help patients fill out forms and 
translate. They may walk patients to the various 
departments or watch for acute warning signs in 
patients who are waiting in the lobby. The 
volunteers also provide emotional support and 
health information to the patient. We find that 
patients often present their symptoms to the patient 
facilitator instead of the doctor, and we get many 
requests from patients for the facilitator to go into 
the exam room with them to serve as a friend and 
advocate. Volunteer training is 8 hours with 
substantial mentoring by existing patient facilitators. 
This program is important because the healing 
process begins when the patient enters the building. 



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Anxiety is a detriment to the effective delivery of 
health care. 

The third program, TEEN TALK LINE, an 
information and referral telephone service for youth 
in our community, is still in the formative stage. 
Platicamos Salud also uses this venue to offer 
health-related information on smoking cessation, 
lung cancer, sexually transmitted diseases, and 
gynecological cancers to youth ages 12 to 19. The 
core curriculum training consists of presentations by 
community social service agencies, lectures on 
counseling techniques, active listening, and role 
playing of possible scenarios. The core training 
totals 40 hours v/ith additional continuing educa- 
tion hours required. A trained adult behavioral 
health professional is always on-site. 

The fourth program is a binational environmental 
health needs assessment and subsequent public 
education campaign funded by the Environmental 
Protection Agency. Our sister city of Nogales, 
Sonora, has seen explosive growth in its population 
over the past 10 years. Presently, 300,000 people 
live in the city without the infrastructure to 
adequately support its citizens. Particulate matter 
from unpaved roads is the primary source of air 
pollution. Other problems both Nogales experience 
are a spontaneously burning landfill containing 
hazardous materials and raw sewage that flows 
north into the Nogales Wash during periods of rain. 
Perhaps because of these environmental problems, 
Nogales, Arizona, has the highest recorded 
incidence of lupus in the world and four times the 
recorded incidence of multiple myeloma. 

Our fifth program is Juntos Contra El Cancer 
(Together Against Cancer), funded by the National 
Cancer Institute. The overall program goal of 
Juntos Contra El Cancer is to increase knowledge 
of cancer prevention strategies among residents. Its 



objectives are to: 

^ Teach community lay health educators at Mariposa 
Community Health Center to talk with clients about 
early warning signs and provide information on 
prevention of cancer and lupus; 

>► Train the lay health educator to facilitate cancer 
support groups; Train a subsequent group of 
volunteer educators to provide information on 
cancer and lupus; and 

5> Evaluate the effectiveness of transferring cancer 
prevention information and educational skills from 
health professionals to lay health educators, and 
subsequently from the original group of lay health 
educators to successor volunteer educators. 

Outcomes 

An effective promotora model has a variety of 
important outcomes to be measured at different 
community and organizational levels— for example, 
changes in the health behavior of the client being 
served and the client's family or changes in the 
overall health characteristics of the community, 
such as the adequacy of prenatal care, postpartum 
services, or the number of residents screened or 
immunized. In most promotora programs, the 
impact of the program on the lay health workers 
themselves is an important outcome. This might 
include the lay health educators' assumption of 
community leadership roles, their transition to 
professional positions, or a retum to school for more 
formal education. 

In conclusion, I'd like to quote Dr. Joel Meister, 
Assistant Director of the Arizona Department of 
Health Services: "Lay health workers bridge the 
gaps between the haves and have-nots of our 
society, and can play a significant role in creating a 
democracy of knowledge and a democracy of 
health." 



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THE HEALTH LIBRARY: 

A MODEL FOR COMMUNITY 

HEALTH INFORMATION 

ACCESS 

Jennifer Cain Bohrnstedt, M.P.A. 

The l-teaitii Library 

Palo Alto, California 

ABSTRACT 

The Health Library, a 6+-year nonprofit 
community-sponsored health information library 
and resource center, originated with Stanford 
University Hospital's Office of Community and 
Patient Relations. Other community health 
providers quickly became sponsors, and the model 
is presently evolving to include corporate 
sponsorship as a primary means of enhancing 
employee satisfaction and wellness. Since opening 
its doors in 1989, The Health Library has served 
more than 100,000 patrons— most of them free of 
charge. The genesis of this particular model of 
service to diverse consumers, patients, and health 
care workers has extended beyond the original 
vision and now is a primary vehicle for linking with 
other nonprofit organizations in the extended 
community. Burgeoning demands for health 
information access are creating new opportunities 
and challenges among the senior community, youth, 
minority populations, and others. 

The Genesis of the Consumer Health 
Information Movement 

There are probably many theories explaining the 
impetus for consumer health information centers. 
One of the most recent, and logical explanations, in 
light of health care reform and cost containment, is 
simply that market conditions have dictated a 
radical transformation to individual ownership of 
health. In the 1960's, a powerful social movement 
began across the country. Some call this the 
consumer movement or the consumer's- 
right-to-know era. Historically, this was at a great 
intersection of other social movements — civil 



rights, women's liberation, truth-in-lending 
disclosure, freedom of information, and many 
others. Over the past 10 years, consumer demand 
for health information has similarly emerged. 

History 

The concept of a community health library in 
Stanford, California, began in 1985 when a small 
collection of health information resources was first 
envisioned, primarily for hospital patients. Later, 
the brainstormers, as they were called, began to 
include information for our growing senior citizen 
community. From community needs assessments, 
they learned that the interest and demand for health 
information extended beyond those groups. The 
entire community was eager for improved access to 
health information. 

Individuals from diverse backgrounds— both inside 
and outside of the health care community— began to 
formulate the essence of what became a grassroots 
movement. What was extremely fortunate about 
our community was that the high levels of energy 
and entrepreneurial spirit behind the movement for 
a health information library were coupled with the 
leadership of one of the nation's top medical centers 
and hospitals, Stanford University. Another 
significant characteristic that still contributes to the 
success of The Health Library is our geographical 
position at the gateway to Silicon Valley, the capital 
of the high-tech industry. 

Despite the extraordinary goodwill for a community 
health library, funding for the library was a critical 
issue. The proposed budget could not be supported 
entirely by the hospital. Foundations were reluctant 
to fiind operating expenses. However, other health 
care organizations that had been part of developing 
the library concept became financial sponsors as 
well. These organizations, while to some extent 
competitors for patients, saw the advantages in 
collaboration. 

The real impetus for the project's commencement 
occurred when the Stanford Shopping Center 
offered The Health Library free rent, worth 
$47,000/year in prime retail space, for 1,050 square 
feet in the most successful regional shopping 
complex. This generous offer was pivotal in the 



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future direction of The Health Library. Located on 
the border of the jurisdictions of two cities, Palo 
Alto and Menlo Park, the Stanford Shopping 
Center's offer was very attractive— ample free 
parking, convenient access to public transportation, 
and a high volume of shoppers and other visitors. 
By all known accounts, Stanford Shopping Center's 
venture with The Health Library is unique among 
the Nation's shopping complexes. 

Core Competencies 

Since opening in August 1989, The Health Library 
has served more than 100,000 patrons. The Health 
Library carved a defined niche in the business of 
providing the community with access to medical 
and health information. Working with an advisory 
board comprising community members, medical 
professionals, and others, a mission statement 
focused The Health Library's work on providing 
scientifically based medical information to 
consumers. The Library adheres to this focus and 
has established processes to ensure the continuing 
integrity and quality of its growing collection. 
Importantly, The Health Library works as an adjunct 
resource to the medical community; it does not 
dispense medical advice or opinion. 

The collection includes more than 4,000 volumes, 
access to online databases, anatomical charts and 
models, clipping files, medical journals, and 
extensive video- and audiotapes. The collection 
contains many materials in both Spanish and 
Chinese. Patrons may use all materials in the 
library at no charge; a small membership fee is 
required to borrow materials. 

Over time. The Health Library has also incorporated 
a Community Education Outreach component. We 
successfully conduct an annual event. The Great 
American Health Controversies, that provides 
debate and dialogue among different perspectives in 
medicine. The Health Library staff members are 
also very visible in the community, participating in 
health fairs and corporate blood-bank drives and 
collaborating with many other associations and 
grass roots groups, such as the Community Breast 
Health Project. 

The Health Library is on the Internet, too, and 



recently became part of the Public Access Network 
(PAN), an effort inspired by projects of the Global 
Information Infrastructure (Gil) initiative to create 
an electronic community based on an advanced 
information infrastructure in education, health care, 
local government, business, and the home. Thus, in 
effect, electronically connected patrons around the 
world can access The Health Library through our 
Homepage: http://ww.med.stanford.edu/healthlib/. 
Users will be able to research carefully selected 
medical databases that The Health Library's 
Homepage will provide free of charge. 

Who are The Health Library's Patrons? 

The three primary groups include the following: 
(1) individual lay persons— patients, potential 
patients, their families and friends; (2) medical care 
providers; and (3) the community at large. 
The people who walk into The Health Library "in 
the dark" about a medical issue quickly become 
hearty users of the resources and often are vocal 
advocates of The Health Library among friends. 
Simply put, knowledge is empowering. In a typical 
week. The Health Library will have visitors or 
callers requesting information on topics from health 
and wellness sfrategies to disease prevention and 
treatment. What happens to these patrons, or 
customers, from their experience in our facility? 
The testimonials are truly overwhelming. People 
tell us that their fears or concerns are often greatly 
reduced or alleviated by the time they leave. Some 
have specific information to take back to their 
medical care providers, sometimes even challenging 
their recommendations. Some of them have 
suggested that access to and use of this vital health 
information provides them, for the first time, with a 
sort of "level playing field" when working with their 
medical care professionals. Others simply know 
better how to maximize their choices. As one 
visitor wrote, "There is so much about the drugs that 
are administered for cancer treatment that 
oncologists do not discuss or disclose unless backed 
into a comer. Thank you, for myself, my wife, and 
her cancer support group." 

Medical care providers constitute another set of 
patrons. Although they were not intended as 
pafrons in the original design, we have found that 
practitioners often refer patients to The Health 



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Library for more information, and they benefit from 
staying abreast of the topics and Hterature through 
a user- friendly set of resources. In fact, with the 
graciousness of a donor's sizable memorial gift, a 
satellite site of The Health Library was opened in 
1993 inside Stanford University Hospital. The 
La Verne Wilson Health Library primarily serves 
in-hospital patients, their families, and the medical 
staff of the hospital. In this era of growing managed 
health and managed time, practitioners benefit from 
having a source of education referral that also meets 
their standards for reliable medical information. 
And frankly, as articulated by Kathryn E. Johnson, 
publisher of the Healthcare Forum Journal . 
"Physicians are being forced to redefine themselves, 
and to ask serious questions about whether it is 
possible to absorb the sheer volume of new 
knowledge" (1995, p. 6). 

The third group of pafrons of The Health 
Library— the community at large— consists of 
companies, service organizations, and citizens and 
stands to gain a great deal from the success of The 
Health Library. Initiatives such as Healthy 
Community 2000 remind us that when we work 
together for healthier fiitures, we all stand to benefit 
from healthier economic times. In fact. The Health 
Library actively participates with the Chamber of 
Commerce in encouraging its members to direct 
their employees to the library. And recently, in 
response to growth in visitors from out-of-state, we 
provided local hotels with brochures for their 
guests, because The Health Library has become a 
visitor destination site. 

Access — A Single but Sturdy Thread 

Although The Health Library can be a powerfiil 
vehicle for extending the possibility of healthier 
communities and improved patient outcomes, access 
alone is not sufficient. I think of this as a tapestry 
with many essential threads. Access to health 
information is essential. But, access to quality 
service and support makes it work. 

Another important thread in the tapestry of health 
information empowerment is being savvy to the 
sheer inhibitions and cultural biases against 
association with health care. One of my colleagues, 
Annye Rothenberg, pointed out in her book the 



insights of a community health worker she 
interviewed: "They [families] think they should go 
to the doctor [only] when they are very, very sick, 
not for preventive care. It's difficult for Mexicans 
from rural and small town areas to deal with the 
system here. If they call up a doctor or a social 
worker and get voice mail, they get upset that they 
cannot talk to the person. They don't know what to 
do." (1995, p. 225) 

The Backbone 

I cannot say enough about the importance of 
volunteers for The Health Library. From the onset, 
more than 100 dedicated and professionally trained 
individuals of all ages and from all walks of life 
have devoted their free time to support The Health 
Library as library reference associates. We do not 
have to advertise for volunteers; most of our 
volunteers have used the library first. Some of them 
have specific areas of interest, such as library 
cataloguing or Homepage maintenance. However, 
most are individuals who are professionally trained 
to greet pafrons and offer to guide their use of 
resources until they are comfortable on their own. 
There is a pleasant yet unobtrusive nurturing that 
comes from the volunteer's offer of assistance. 

Tools Needed 
What is the quick checklist of "tools" needed to 
develop such a health library in your community? 

> Identify community needs to be addressed. 

> Focus, ruthlessly. 

> Cultivate a "champion" for your cause. 

> Leverage existing resources— "buy or borrow, don't 
build." 

>- Collaborate— providing access to extensive health 
information is a bigger job than any single 
organization can accomplish. 

^^ Keep it simple. 

>" Begin with the end in mind. 

Future Directions 

Because of The Health Library's success, we are 
beginning to develop new models for satellite sites 
or affiliates in other areas. We are working with 
senior citizen organizations, hospitals outside our 
State, and disease-specific associations that are 
seeking to provide health information rooms or 
centers without reinventing The Health Library's 
wheel. 



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Recognizing that communities, health care 
providers, and individuals cannot all avail 
themselves of a health library to the extent that we 
have, The Health Library has expanded its custom 
research service with a toll-free, 800 number (1- 
800-245-5177). Membership and participation in 
The Health Library are not conditional upon 
geography. We have members around the world. 

One local newspaper has asked us to develop a 
Question & Answer forum for area readers. 
Because some of our most frequently asked 
questions pertain to pharmaceutical drugs. The 
Health Library will explore the development of a 
grant proposal to insurance and pharmaceutical 
companies for a pilot program to have a pharmacist 
on duty at the library. With more than 12% of our 
community over age 60, and more of the "boomers" 
headed there, we are regularly seeing individuals 
with bags of pharmaceutical drugs asking questions 
about drug interactions, for example. In many 
ways. The Health Library's work has just begun; we 
have just scratched the surface of proactive service 
possibilities. Given our location, environment, and 
the nature of our community patrons. The Health 
Library's will continue to explore and exploit, in the 
most positive sense of the word, whatever new 
technologies emerge that put the individual's ease of 
accessing health information at the forefront. 



The Health Library is a replicable model for many 
communities. The Health Library's staff members 
provide consulting services for those who wish to 
take a similar leap in their communities with 
resources such as ours. The Internet can also bring 
you almost to The Health Library's doors, on our 
Homepage, and without a plane ticket. However, 
for those who do not have the time to build their 
own model and who want more than electronic 
access, an affiliation with The Health Library is 
possible through our satellite site program. There is 
something to be said about working with the 
expertise of the pioneers. 

The principles described here are really quite 
simple, although the implementation is far from 
that. Once people have a successfiil experience 
gathering and using information on health issues for 
themselves or their families, they will not easily 
return to their prior state of passivity and/or 
ignorance. That first successful experience is very 
critical, but once hooked, the "information is power" 
model is addictive. With access to health 
information, health consumers can choose among 
options, understand and assess recommendations, 
and, in general, exert more control over their lives. 

You, too, can make that happen. 



REFERENCES 



Johnson KE. The Radical Write. Healthcare Forum 
Journal . 1995; May/June (6). 

Rothenberg BA. Understanding and working with 
parents and children from rural Mexico . MenloPark, 



CA: CHC Center for Child and Family Development 
Press, 1995. 



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INTERNET AND GEOGRAPHIC 

INFORMATION SYSTEM 

TECHNOLOGY: BRIDGING 

THE U.S.-MEXICO 
INFORMATION FRONTIER' 

Deborah A. Salazar, Ph.D. 

Bureau of Economic Geology 

The University of Texas at Austin 

ABSTRACT 

This paper discusses two technologies of urgent 
interest to health educators and epidemiologists 
working in the U.S.-Mexico border region— the 
Internet and Geographic Information Systems 
(GIS). These technologies offer new analytical 
advantages to health care professionals and have the 
potential to dramatically alter the flow of health 
information in this binational region (Beck, Wood, 
and Dister 1995). The Bureau of Economic 
Geology (BEG), a research unit of The University 
of Texas at Austin, is actively involved in basic 
research that seeks to expand the technological 
approaches to environmental and health education. 
BEG is designated as a CIESIN (Consortium for 
International Earth Science Information Network) 
Internet node for the entire U.S.-Mexico border 
region to facilitate access via the Internet to 
organizations, programs, and reference materials 
concerned with environment and health. In 
addition, BEG works on many projects using GIS 
technology to map and analyze environmental data 
in the border region, which are also of interest to 
health professionals. Both the Internet and GIS can 
help health professionals exchange data across the 
border, improve understanding of local health and 
education needs, and assist in tracking the cross- 
boundary movement of water, air, and contaminants 



'Publication authorized by the Director, Bureau of 
Economic Geology, The University of Texas at Austin 



that have a direct impact on the health of border 
community residents. 

BEG participates in the recently formed 
Transboundary Resource Inventory Project 
(TRIP). TRIP is a binational program that seeks 
to develop data on environmental and natural 
resource issues and to standardize digital data 
formats and exchange protocols for 
organizations and agencies along the U.S.- 
Mexico border. There is currently a burgeoning 
binational interest in digital data in the public 
and private sectors of both the United States and 
Mexico. Health care professionals will greatly 
benefit from the creation of high-quality 
environmental and health baseline data that are 
compatible on both sides of the U.S.-Mexico 
border and are available in the public domain 
(Brown and Wright 1995). This paper reviews 
some of the basic concepts of these 
technological tools and suggests how they can 
help improve access to information and widen 
the available knowledge base for the U.S.- 
Mexico border region. 

The Bureau of Economic Geology 

The Bureau of Economic Geology (BEG) was 
founded in 1909 at the Austin campus of The 
University of Texas. We have a staff of more than 
170 researchers and graduate research assistants 
who work on various research projects, including 
hydrology, geophysics, natural resources, surficial 
geology, waste disposal, water quality and 
availability, and environmental resource assessment. 
As physical scientists, BEG researchers are keenly 
aware that no natural resource stops at the line of 
the U.S.-Mexico border. Soils, geology, air, and 
vegetation continue seamlessly across this political 
boundary. During the course of mapping geologic 
units or evaluating environmental conditions, our 
researchers have often crossed the border to compile 
a balanced picture of resources in the border zone. 
Despite the recognition that environmental data 
continue on both sides of the border, many 
traditional map products (which are generally 
produced with national/Federal funding) either stop 
completely at the border or classify features 



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differently for the U.S. and Mexican sides. The 
scale of published maps (for example, 1 :24,000 
versus 1:50,000) and even the map units (feet or 
meters) are not immediately compatible from one 
side of the border to the other. Language is also an 
obstacle for people who speak only Spanish or only 
English. Unilingual publication of map guides or 
other technical environmental information has 
made it difficult to access information about 
conditions on "the other side." Perhaps the benefit 
derived from the current economic crises, on both 
sides of the U.S.-Mexico border, is a renewed 
motivation to communicate and to share existing 
digital information, thus avoiding the very costly 
duplication of effort that has occurred occasionally 
in the past. Water resources, geologic resources, 
and human resources (as well as diseases) do not 
stop at the border. It is a propitious moment to 
make sure that our data and communications 
infrastructure also reflect this environmental reality. 
Technology, specifically computers with Internet 
and Geographic Information Systems (GIS) 
capability, offers sfrategic advantages in efforts to 
locate and use data from this binational region. 

Internet Resources 

The Internet is a large "network of networks" (Fig. 
1). It connects thousands of computer networks 
into a single communication structure and allows us 
to send e-mail, browse home pages, and download 
data. Links go between educational institutions, 
government agencies, and businesses, and can even 
reach into homes via telephone or cable modems. 
In addition to being the "information 
superhighway," the Internet is also a new and 
exciting medium of communication that allows 
readers to determine their own path to explore 
information. The Internet will be increasingly 
important to all sectors of society as a way to 
transfer data, view data bases online, converse 
through e-mail, conduct business, and even 
schedule appointments or access personal health 
data. One advantage of the Internet is that a 
computer can handle thousands of inquiries at a 
time, surpassing most voice telephone capabilities, 
and it offers a relatively confidential context for 
exploring data or issues of interest to a client. 
Perhaps more importantly, people can go straight to 



the information that interests them, bypassing 
extraneous or peripheral issues. 

Figure 1 . The Internet is a network of 
networks connected via a single addressing 
scheme, the internet protocol (ip) 




From a technical viewpoint, the Internet is a flexible 
network of computer "servers" that allows public 
access to data and programs. Internet "pages" 
present a format for organizing and presenting text, 
graphics, and sound. Browser programs such as 
Gopher, Mosaic, Netscape, or Internet Explorer are 
used to navigate around the network. Search 
utilities such as Veronica and Archie are becoming 
more sophisticated, allowing a reader to send out a 
search inquiry that may touch thousands of servers 
in its efforts to retrieve the desired information. 

The original goal that led to the formation of the 
Internet was to create a computer networking 
system that could send messages without being 
completely dependent on any single line of 
communication. The Internet began around 1969 as 
a U.S. Department of Defense project called 
ARPANET to link computers in a way that could 
withstand power outages (like bomb attacks) (Krol, 
1992). This first project, which founded the IP 
(Internet Protocol) addressing concept used to link 
computers, was dismantled in March 1990. NSFnet, 
directed toward the research and university 
communities, came online in 1986 to support 
communications between five supercomputer 
centers (Krol, 1992). UUCP and Usenet, directed 
toward university and commercial organizations, 
began in the 1970's (Laquey and Ryer, 1993). The 
Internet that we "see" today has changed 
dramatically since the early 1980's. In 1981 there 
were 213 computers on the Internet (Laquey and 



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Ryer, 1993); today there are more than 7 miUion 
servers, and estimates for the year 2000 are close to 
101 million (Fig. 2). Internet connections are most 
numerous in the Western developed world, but 
Latin American countries are gaining in 
connectivity as well. More than 10 million people 
use the Internet directly and more than 25 million 
indirectly (Laquey and Ryer, 1993). Unfortunately, 
this technology is still gender sensitive, as men 
users outnumber women 2 to 1 (Lewis, 1995). One 
of the big changes yet to come to the Internet is the 
balancing of the gender ratio. 

Figure 2. Internet conections are projected 

TO rise dramatically in the next 5 YEARS 




So, what is all the fuss about? It is really about 
communication. Viewing Internet home pages is 
like flipping through the pages of a book, except 
that by using hypertext mark up language (HTML), 
readers can "click" on key phrases. So, for 
example, a reader starts reviewing a document in 
the table of contents and can click on a topic of 
interest like "breast cancer." This click immediately 
propels the reader across three chapters to page 125, 
where there is a discussion on breast cancer. The 
reading audience is no longer confined to a linear 
presentation of information. To extend this concept 
one step further, a reader could click on a topic such 
as "pesticide exposure," found under a Department 
of Health home page, and jump immediately to a 
Department of Agriculture home page containing 
pesticide information, or to a Poison Control Center 
home page containing toxicity data. Hypertext 



hands the keys to the readers and lets them drive, 
stopping at locations where there are useful data or 
information and passing by other locations that are 
of little interest (Fig. 3). 

Figure 3. Cruising the Information 
Superhighway 



INFORMATION 
SUPERHIGHWAY 




The Internet is changing our sense of timing and 
timeliness. It allows for a "live" presentation of 
data because requests can be filtered through real 
data bases and can feed back the most up-to-the- 
second information available. These "real-time" 
information queries are now a reasonable 
expectation for public education programs or 
community outreach projects (Goldman 1994). 
Internet pages can be edited and changed as quickly 
as editing a word-processed document. Readers can 
decide to look for data such as a map of the U.S.- 
Mexico border. They can search the Internet, locate 
data, and then download digital files with the 
desired information in a matter of minutes, rather 
than the days or weeks that telephones and 
conventional mail might require. Of course, the 
administrative challenges of keeping all of these 
data and educational efforts up to date are now 
tremendous. 

The Internet also allows us to more effectively 
bridge the language barrier. Working in the U.S.- 
Mexico border region has always been challenging, 
in part because of the need to consistently present a 
clear and balanced portrayal for both English and 
Spanish speakers (Texas General Land Office 
1995). Using hypermedia, a bilingual interface is 
much simpler to construct. You can have a 
buttonmarked "push here for Spanish" (Fig. 4) (or 
French, Chinese, etc.) that leads the reader to a 



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separate portrayal of the Internet page in his or her 
preferred language. This eliminates the need for 
side-by-side translations of documents, which are 
usually unwieldy to design and difficult to read. 
Most word processing programs have an expanded 
ASCn character set that can handle the orthography 
of many foreign languages— accents, tildes, and 
umlauts. 

Figure 4. Language buttons can simplify 
switching to a page in a reader's preferred 

lANGUAGE 



About the GAS 






This Week at the OAS 






Toward Free Trade in the Americas 




English 


OAS Programs and Activities 


Public Information 
Documents of the OAS 




Espanol 


Gophers and Webs of the Americas 









hi addition to the Litemet's rapid update capability, 
and a bilingual or multilingual interface that is 
relatively transparent to readers, the Internet is also 
making progress in improving communications 
access in regions that still experience limitations in 
voice telephone access. Advances in cellular 
connections make it possible for a doctor or 
researcher working in a remote region with no 
access to a physical library to use a computer to 
access an online "virtual library" via the Internet. 

BEG participates in an Internet navigation project 
called the Regional Environmental Information 
System (REIS), which is designed to make 
environmental and health data from the U.S.- 
Mexico border region publicly accessible. It is one 
of several regional Internet projects sponsored by 
the Consortium for International Earth Science 
Information Network (CIESIN) through funding 
from the U.S. Environmental Protection Agency 
(EPA). The goal of the project is to provide "links" 
to other major sources of environmental, social, and 
health-related data for the border. The REIS 
"gateway" allows readers to search, view, browse, 
and order copies of data from hundreds of servers 
on the Internet and can complete searches of 



"virtual archives" across hundreds of servers 
without the reader being aware of its travels. The 
gateway focuses on information about human 
interactions and global environmental change, 
drawing on resources from entities such as the 
National Aeronautics and Space Administration 
(NASA), the Global Change Master Directory 
(GCMD), the Socio-Economic Data and 
Applications Center (SEDAC), and the National 
Oceanic and Atmospheric Administration's (NOAA) 
Environmental Services Data Directory (ESDD). 
Each data set accessed through links in the REIS 
home page is "owned" and maintained by the 
individual agency that developed it, and each of 
those organizations determines its own policy for 
data access and update. 

REIS also gives an overview of the administrative 
structure of organizations on both sides of the U.S.- 
Mexico border, including the Instituto Nacional de 
Estadistica, Geografia, e Informatica (INEGI); the 
Secretaria de Medio Ambiente, Recursos Naturales, 
y Pesca (SEMARNAP); the U.S. EPA; and the U.S. 
Fish and Wildlife Service (USFWS). State agencies 
and nongovernmental organizations are also 
included in the listings. A number of data sets are 
available from these organizations online, as well as 
many useftil bibliographies and data set guides, 
including: 

> Agency for Toxic Substances and Disease Registry's 
Hazardous Substance Release/Health Effects Data 
Base 

> CIESIN's Georeferenced Population Data Sets of 
Mexico 

>> CIESIN's Integrated Population, Land use, and 

Emissions Data Project 
>► Texas Cancer Data Center Online Data Bases 
>> Texas Department of Health EPIGRAM 

(Epidemiologic Data Base) 

> Texas Natural Resources Information System, 
Texas/Mexico Borderlands Data and Information 
Center 

One of the unique features of the REIS Internet 
home page is its spatial data viewer. Using GIS 
technology, an online reader can examine a wide 
range of spatial data or maps from the border 
region. This particular capability is new to the 
Internet environment but should become more 



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common in the next few years. The computer 
accepts a request for information about a particular 
region and then searches a spatial data base, 
constructs a map graphics file, and then sends that 
information to the reader's computer screen. 

Geographic Information Resources 

GIS technology has been used in universities and 
research centers for 15 years or more, but because 
of the high cost of computers and software and 
because of the complexity of maintaining the large- 
sized data bases, this technology is not yet 
widespread. Advances in computer hardware and 
software, especially faster processing chips and 
mass storage devices, have created the possibility of 
using PCs and Macs as workable GIS platforms 
(although most researchers still use UNIX 
workstations). In many application areas, such as 
in public health, GIS is a new data analysis tool. 
GIS is an expert system of computer hardware, 
software, personnel, and geographic or 
georeferenced data. It uses a "relational" data base; 
in other words, a map has a table linked to it with 
relevant explanations for what each line or space 
represents (Fig. 5). 

Figure 5. GIS uses a relational data base, which 

CONNECTS A MAP GRAPHIC AND A TABLE 




^ — 


Table.dal 




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UiKja 


Type 


Cods 




1 


A 


21 




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Count 




21 


2 


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There are two primary data formats for GIS 
applications— raster and vector (Fig. 6). Each 
format has particular advantages and drawbacks in 
ease of analysis or beauty of representation. Raster 
approaches divide the data into grids of equally 
sized pixels. A space is defined not by its bounding 



outline but by a series of related pixels. Raster data 
have certain quantitative analytical advantages. 
Vector formats represent data with point, lines, and 
polygons as the basic unit of analysis. Polygons 
tend to emphasize a regional approach to analysis 
and make for elegant topographic representations. 
Within the vector world, data are represented by a 
spatial surrogate as either points, lines, or polygons. 
All the data features that are added into a GIS data 
base, such as disease incidence, average population 
density, median income, or residential streets, are 
represented as by a spatial surrogate either a point, 
line, or polygon. The design of a GIS application 
focuses on how best to represent real-world features 
in the digital format. 

Figures. Two basic approaches to data 
representation in gis— raster and vector 







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SRECNO 


USER-ID 


SUtT 


OWNER 


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A GIS data base is composed of a number of data 
layers or digital files. One of the many strengths of 
using GIS as a method of analysis is that it allows 
the reader to visualize the data as thematic layers 
and then to analyze, either in qualitative or 
quantitative terms, the interaction or 
interdependence of those data (Fig. 7). For 
example, there may be a clear spatial 
correspondence between vegetation and geology or 
between household income and cases of 
tuberculosis. This overlay analysis approach is, in 
fact, similar to traditional approaches to multiple 
regression in that we are looking for significant 
combinations of factors to explain some 
phenomenon or landscape pattern. 



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Figure 7. Overlay analysis in CIS compares 

A4ANY LAYERS OF MAP INFORMATION 



^y^ Hydrology 
^y'^ Topography 



z 



y^ Average Income 
^ Ethnicity 

^^^ Streets 

^X^Census Blod<s 
^ Census Tracts 





The objective of spatial analysis is to answer 
questions in which location matters; this is 
philosophically different from assuming that 
phenomena are distributed homogeneously through 
space. We know that location is an important 
aspect of most epidemiologic topics. Many 
infectious disease and environmental disease risk 
factors are not "randomly" distributed over space. 
GIS is a structured, organized method to begin to 
explore many of these relationships and 
associations. 

GIS helps to organize spatial data, but the 
researcher must determine the units and scale of 
study. In an analysis of cholera incidence, for 
example, we might construct a data base at the 
national level, perhaps subdivided by State, and for 
each State collect relevant environmental and 
population data. Eventually, disease incidence 
could be plotted in relation to significant features 
like cities, rivers, or international borders. The 
scale of the data is critical to the analysis. Some 
topics can be investigated at a global level, whereas 
others require more specific regional or local 
information to make sense of the patterns. Most 
experts agree that more than 70% of the total cost 
and time of a GIS project will be expended in 
constructing the data base. The most efficient plan 
is to make the best compromise possible between 
the goals of the project and the scale of data needed 
for analysis. Large-scale data (with large amounts 



of detail) are more expensive to integrate into GIS 
than small-scale data. Several businesses have 
recently begun to make available small-scale digital 
data of political boundaries or environmental 
features. It is, however, the large-scale data, 
composed of local features, topography, or specific 
streets and neighborhoods, that are both expensive 
and computer-space intensive to produce and 
maintain. Recent legislative changes in many States 
now recognize digital data bases as major 
investments and as having a real, quantifiable value 
that develops over time. Although it is preferable to 
work with data that are already in a digital format, 
"hard copy" data must also commonly be converted 
for use. Digitizing tablets are a traditional way of 
entering spatial data manually into the computer 
system. High-resolution scanners can also achieve 
this task. 

Another advantageous feature of GIS is that it 
allows researchers to integrate data from a variety of 
sources, such as combining remotely sensed satellite 
images or high-altitude photography with 
topographic or street data. Satellite imagery, aerial 
photography, and global positioning systems allow 
readers to ground the maps in real-world 
coordinates and map units. Spatial accuracies of 5 
meters, or even less than 1 meter, are now possible 
(although still relatively expensive for most health 
applications). With more precise data, it is possible 
to complete more detailed environmental modeling, 
such as surface terrain models (digital 
representation of topography) or models of the flow 
of water or erosion potential. Surface models can 
also represent cultural features, such as population 
density or disease incidence over space. 

Perhaps one of the most urgent data needs in the 
health care community is a way to "geocode" 
locations of patients or disease cases and confrols 
through address matching. Address matching is 
achieved through a computer program that takes 
street network data (in a geographic coordinate 
system) and locates an address based on address 
ranges in the street data (Fig. 8). The computer then 
calculates a discrete point value for the address. 
Once geocoded, the distribution of cases and 
controls can easily be analyzed in comparison with 



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Other environmental or socioeconomic data. Most 
GIS allow a researcher to take a file of many 
addresses and geocode them in batches. Address 
geocoding is computer-time intensive. There are 
private companies that are willing to match batches 
of addresses for a fee. Addresses (which are often 
confidential information) also can be stored in- 
house in a point form, but generalized for public 
use so that privacy can be maintained. 

Figure 8. Geocoding or address matching is a 
basic activity for most health-oriented gis 
projects 




Data that can be purchased from private businesses 
often include many copyright restrictions in use or 
display that make it difficult to use that data for 
research or public education. Data that are 
produced in public agencies are free from these 
copyright restrictions and can be copied and used 
openly (although citation of the original source of 
public data is always sfrongly recommended). 
Sharing public digital data is, perhaps, the most 
economical strategy for making GIS more 
accessible to the public. Several data centers have 
formed that act as brokers of digital data on a 
regional basis. Most often these centers are Federal 
or State agencies that already have a mandate to 
provide information to the public. For example, the 
U.S. Geological Survey (USGS) is already a major 
supplier of map data. It is currently phasing out 
many of its print map series to focus instead on 
digital map products, such as the digital elevation 
models, digital orthophoto quads, and digital raster 
graphics. Because of their detail and accuracy. 



these products serve as base map data for many 
environmental research projects. The U.S. Census 
Bureau develops and distributes the TIGER 
files— street network data for the entire United 
States. These files are based on the Census Bureau's 
vast elecfronic data base used to conduct the 
decennial census. The TIGER files have address 
ranges for most of the urban areas, although rural 
areas may not yet have that level of detail. 

Regional data distribution centers, such as the Texas 
Natural Resources Information System (TNRIS) in 
Austin, play a crucial role in archiving and 
distributing many kinds of geospatial data. 

TNRIS holdings include Census TIGER files, USGS 
topographic quads, aerial photography, and some 
satellite imagery. Also, TNRIS archives and 
distributes data from both the United States and 
Mexico via INEGI and other Mexican institutions. 
TRIP, the Transboundary Resource Information 
Project, is another binational initiative focused on 
geospatial data. The participants of TRIP are 
working toward solutions to integrate the digital 
map products of both the United States and Mexico 
to create seamless data sets that cover the entire 
region. 

New Skills for Health Care Workers Along the 
Border 

Internet and GIS technology are revolutionizing all 
aspects of research and information handling. It has 
transformed the environmental sector and will have 
a major impact on the health education field in the 
next 10 years (Beck, Wood, and Dister 1995). 
Together, these two technologies are creating a 
useful framework to facilitate almost instant access 
to data. The ability to work with data in a large 
number of digital formats and to provide global 
access to data at the cost of reproduction will enable 
health care professionals to use this technology to 
better analyze their environmental health questions 
and communicate health concepts to the general 
public in a more flexible, multilingual format. 
These technologies will undoubtedly serve as 
important tools in supporting the health care and 
research communities to achieve the overall goal of 
better health and productivity in the U.S. -Mexico 
border region. 



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Selected Internet Sites 

>* Texas Water Development Board 

http://www.twdb.state.tx.us 
Ss' Texas Natural Resources Information Center 

http://tnris.twdb.state.tx.us 
>► Imagenet (Preview Satellite Imagery) 

http://www.coresw.com 
>* Consortium for International Earth Science 

Information Network (CIESIN) 

http://www.ciesin.org 
>* Regional Environmental Information System 

(REIS) 

http://begss 1 .beg.utexas.edu:8888 
>► HazDat 

Http://atsdrl .atsdr.cdc.gov: 8080/atsdrhome.html 

> Transboimdary Regional Information Project (TRIP) 
http://www.glo.state.tx.us/infosys/gis/trip/ 

>* Bureauof Economic Geology 

http ://www.utexas . edu/research/beg 
^ Directorio de America Latina 

http://www.globalnt.com 

> U.S. Enviroimiental Protection Agency 
http://www.epa.gov 

>- Health Yahoo 

http : //www . yahoo . com/health/ 



Centro Nacional de Informacion y 

Documentacion Sobre la Salud (CENIDS) 

http://cenids.ssa.gob.mx 

Latin American Network Information Center 

http : //lanic . utexas . edu 

U.S.-Mexico Borderlands Environmental 

Archives 

http://www.greenbuilder.com/mader/ecotravel/~b 

order/borderlands.html 

Border Information and Solutions Network 

http://www.vt.com:80/~bisn/ 

Centers for Disease Control and Prevention 

http://www.cdc.gov/cdc.htm 

U.S. Department of Commerce, Bureau of the 

Census 

http://www.census.gov 

Geographic Information Retrieval 

http://wings.buffalo.edu/geoweb/ 

U.S. Geological Survey (USGS) 

http://www.usgs.gov 

Instituto Nacional de Estadistica, Geografia, e 

Informatica (INEGI) 

http://inegi.gob.mx 



Beck, Louisa, Byron Wood, and Sheri Dister, 1995. 
Remote Sensing and GIS: New Tools for Mapping 
Human Health. Geolnfo Systems 5(9):32-37 

Brown, Christopher, and Richard D. Wright. 1995. 
Directory of Spatial Datasets to Support Environmental 
Research Along the United Sates-Mexico Border. San 
Diego: Institute for Regional Studies of the Califomias, 
SDSU. 

Goldman, Daniel. 1994. The EPIGRAM Computer 
Program for Analyzing Mortality and Population Data 
Sets. Public Health Reports. 109(1):118-124. 



Krol E. The whole Internet: User's guide and catalog . 
Cambridge, MA: O'Reilly and Associates, Inc., 
1992.Laquey T, Ryer J. The Internet companion: A 
beginner's guide to global networking . Reading, MA: 
Addison- Wesley Publishing Co., 1993. 

Lewis PH. Demographically, the Internet is still a 
frontier town, though with more women than expected. 
New York Times, May 29, 1995;144:21, col.l. 

Texas General Land Office. 1995. Transboundary 
Resource Inventory Glossary: Spanish-English 
Cartographic Environmental, and Oil SpiU Terms. Austin: 
General Land Office. 



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CREATING SUPPORT SYSTEMS 

FOR COLOMIA WOMEN 

THROUGH A LAY HEALTH 

PROMOTION OUTREACH 

PROGRAM 

Elida Hernandez 

Josefa Rodriguez, L.V.N. 

June Grube Robinson, IVI.P.IH., R.D. 

Midwest Migrant Health 

Information Office 
Rio Grande Valley, Texas 

ABSTRACT 

This paper describes a program that created social 
support systems among women living in colonias 
(neighborhood) in Hidalgo and Cameron Counties, 
Texas. The Home-Base Health Education program 
trained migrant farmworker women as lay health 
promoters. Participants were selected from among 
those who serve as health promoters in their migrant 
labor camps in other States during the summer. 
Participants were familiarized with the health issues 
and health and social services relevant to colonia 
residents. After training, the health promoters went 
into colonias and arranged health education 
sessions. Two levels of support systems were 
created. The health promoters supported each other 
as they discovered new capabilities within 
themselves to learn and help others. In turn, they 
supported colonia women who were learning about 
and dealing with mental and physical health issues 
affecting themselves and their families. 

IHE Beginning 

Since 1983, the Midwest Migrant Health 
Information Office (MMHIO) has worked to 
improve the health of migrant farmworkers and 
families through community-based programming in 
health education and advocacy. With funding from 
the Federal Office of Migrant Health and the W.K. 
Kellogg Foundation, MMHIO has developed, and 
has assisted others to develop, peer health 
promotion programs such as the one based in the 



Rio Grande Valley (Valley). MMHIO began 
working in the Rio Grande Valley in 1987. The 
health education programs in the Valley grew out of 
the Camp Health Aide Program that trains 
farmworkers to be health promoters in labor camps 
and communities when they are away from their 
home base. 

Downstream Program 

As a result of its success and the need for year- 
round health promotion in the colonias and migrant 
farmworker communities, MMHIO developed the 
Downstream Program. The Downstream Program 
services farmworkers who have been Camp Health 
Aides in the northern States and provides them with 
an opportunity to continue their education when 
they return to their home base in the Valley. 
Supervised by health professionals, aides serve as 
interns at various health organizations and agencies 
in the area. Among those participating in this 
capacity are the Texas Migrant Council, the 
Weslaco Holy Family Birthing Center, Project Arise 
in the Las Milpas Colonia, some WIC (Special 
Supplemental Nutrition Program for Women, 
Infants, and Children) centers, and public schools. 

Outreach 

In 1992, MMHIO secured funding from the Kellogg 
Foundation to develop and implement a colonia 
outreach program, which has been operating in the 
Valley for the past 2 years. The program provides 
migrant farmworkers and colonia residents with 
health education information, and skills. It also 
provides experienced Camp Health Aides with 
professional growth opportunities. 

Camp Health Aides who were selected for the 
colonia outreach program participated in over 200 
hours of health education. Topics included family 
planning and birth confrol, prenatal care and breast- 
feeding, parenting and child development, chronic 
and communicable diseases, domestic violence and 
child abuse and neglect, depression, substance abuse 
and gangs, STDs and HIV/AIDS, cancer signs, 
breast self-examination, and folk medicine. 
Following David Werner and Bill Bower's model, as 
described in their book Helping Health Workers 
Learn, the fraining design included community- 
based health education using interactive classroom 
instruction, group discussion, brainstorming. 



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observation, and role assimilation. Representatives 
from health and social service organizations helped 
familiarize health promoters with local resources, 
and participated in training as presenters at various 
health care sessions, workshops, and classes. The 
first year of operation was quite successful and 
effectively prepared participants for the second 
season of the program. 

Health promoters began the 1994-95 season with a 
review of various health care issues to which they 
were introduced and in which they became skilled 
during the previous season. This phase was 
designed both to provide health education to colonia 
residents and communities and to enable health 
promoters to gain hands-on experience. 

Every effort was made by the Program Coordinator 
and the health promoters to eliminate barriers to 
participation for colonia residents. By design, the 
program removed many structural barriers such as 
lack of transportation, language, child care, and 
spousal objections. 

In an effort to overcome any existing or potential 
barrier, health promoters contacted and met with 
residents at their homes in various colonias. In 
preparation for disseminating health information to 
their peers, health promoters also facilitated group 
brainstorming and discussion sessions to identify 
health care issues of interest and concern to 
participants. To further ensure full attendance at all 
health education sessions, colonia residents 
collectively arranged convenient meeting times. 
Therefore, colonia residents, by essentially 
designing their program and curriculum, were 
personally involved at every level of this program. 
In addition to sharing their skills and knowledge as 
health educators with colonia and migrant 
communities, the health promoters were also 
responsible for providing an overview of the 
program to groups of participating residents, 
including its goals and purposes. They also 
contacted various health service providers who 
ultimately participated in this program as 
cofacilitators of health education workshops and 
classes. 

As would be expected under this program design, 
which is based on principles of participatory 



instruction, each health session and all materials 
presented were relevant to the lives of the health 
promoters, colonia residents, and community 
group participants. Sessions, workshops, and 
classes were based on their experiences— as 
laborers in camps, as residents of the colonias, and 
as a population with little or no access to health care 
services or information. 

Following these same principles, workshop 
materials, exercises, and activities were designed to 
enable participants to examine and analyze 
situations, enhance thinking and problem solving 
skills, and tap into their natural abilities, instincts, 
and knowledge for addressing health needs. 

Outcomes 

The comprehensive support system for colonia 
women through MMHIO's Home-Base Health 
Education Program was instrumental in successful 
program outcomes. Women had access— some, 
perhaps, for the first time— to various levels of 
support. Colonia women were supported by friends 
and neighbors and by health promoters in health 
and/or personal situations— situations that would 
have previously been kept to oneself. Life as a 
migrant farmworker is difficult enough; this level of 
support— a simple sharing with others of personal 
situations— relieves undue sfress and hardship 
associated with this difficult life. 

Another way in which colonia women were 
supported was through the availability of health care 
information relevant to their own lives, providing 
them with the confidence as well as the information 
they need to handle situations on their own for 
themselves and their children. 

In addition to the above, health promoters were 
supported by one another as they shared the 
responsibility of teaching and disseminating health 
information in colonias; they gained support and 
furthered their knowledge and skills as a result of 
the supervision they received from local health care 
professionals. The ongoing support they received 
from the Program Coordinator provided health 
promoters with the confidence and further 
knowledge they need to continue in leadership 
positions and to further their education in the health 
field. 



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Werner D, Bower W. Helping Health Workers Learn . 
Palo Alto, CA: The Hesperian Foundation, 1982. 



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HEALTH EDUCATION FOR 

NONREADERS: TRANSLATING 

ACROSS CULTURES 

Aracely Resales 

Latino Health Literacy Project 

Health Promotion Council of Southeastern 
PA, Inc. 



ABSTRACT 

The Latino Health Literacy Project reaches and 
educates people with different cultural 
backgrounds, who also have limited reading skills. 
This project develops, translates, and distributes 
health educational material for low-income, poor 
readers in its Latino community. 

The United States is a country with people of 
diverse cultural and ethnic backgrounds where 47% 
of U.S. adults read at or below the 8th-grade 
reading level. However, most educational materials 
in English and Spanish continue to be developed or 
translated for persons reading at a lOth-grade level, 
with little attention to different cultural values. 
This workshop shares strategies we have learned 
from adult educators and health educators. 
Through experiential exercises, participants gain a 
sense of what it is like to not understand. They 
learn effective methods of written materials 
assessment, development, and translation, and they 
participate in materials revision. 

Assessing the Target Population 

Do not translate just any existing materials 
available in English. Try to determine who your 
target populations are and what some of their 
special educational needs are. Needs assessment, 
focus groups, and advisory groups will help you 
find out about your target population and their 
educational needs. 



Try to find out what types of educational efforts 
have worked in the past and which have failed and 
why. 

Making Materials Culturally Relevant 
People who feel connected to their cultural heritage 
and identity are often better able to accept new 
information and to use this motivational information 
to make changes. If the material does not attract or 
does not appeal to the target population, chances are 
they will not read it, or, even worse, they will not 
pick it up. 

To make materials culturally appropriate you must: 

> Get community input when designing new 
materials. Sometimes it helps to have a group of 
people writing the content of the material. 

>" Incorporate cultural values, beliefs, and practices 
into your material. But do not forget that some of 
these beUefs could also be misconceptions, and you 
must discourage them by including the facts or the 
right information. 

>* Include messages that are locally and regionally 
relevant. Ask people how to say or what to call 
things in your area. 

>* Use community people to tell positive stories and/or 
testimonials. This method will increase credibility 
and interest in the topic and enhance personal 
involvement and relevance. 

Writing Materials in the Appropriate Language 

You must write the material in the language that the 
target group speaks; however, it is important to pay 
attention to the differences in vocabulary among 
cultural subgroups. For example, the majority of 
Latinos speak Spanish; however, some subgroups 
use different words to name the same things. On the 
other hand, sometimes the same words have 
different meanings among subgroups. (In fact, 
some of these words can have very unpleasant 
meanings.) 

Therefore, when writing or translating materials: 
>" Use the specific words and phrases that are used by 

the target population. 
>■ Be as explicit and direct as the culture will tolerate. 

Ask people what is acceptable and what is not. 
>* Direct your text to a specific subgroup. 

There are cultural differences among some 
subgroups, for example, Puerto Rican, Mexican, and 
Central American, especially when it comes to food. 



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For example, because there are several subgroups 

among Latinos, it is important to: 

> Adapt the text to a universal, more neutral and 

simple Spanish that can be understood by all 

subgroups. 
>" Adapt the text to a specific subgroup making it 

more culturally sensitive, direct, and effective. 
^ Do not forget to name your target audience in your 

title or on your cover page, for example, "Guia para 

Puertorriquenos" (Puerto Rican Guide). 

Recommendations for Translating 
THE Content 

>- Avoid direct or literal translation from English 
to other languages. Other languages cannot be 
matched word for word with English. Literal 
translation can result in stiff phrases that do not 
flow with the richness of the other languages. 

>^ Idiomatic expressions cannot be translated. 
Idiomatic expressions have meaning only in the 
language in which they were created. Try to 
translate the meaning of the expression. You can 
also look for a similar expression in the language in 
which you are writing. 

5^ Translate materials that are written in English 
in their final version only, not in the draft form. 
Translating materials that still need revisions in 
English will be time-consuming because new 
translations will have to be made for the edited 
English version. 

Writing Materials at the Appropriate 
Reading Level 

Because literacy is also a problem among 
communities of other cultural groups, remember to 
develop educational materials that are not only 
culturally sensitive but are also easy to read. Keep 
written materials brief by using the same principles 
you would use in developing low-literacy materials 
in English. 

To evaluate the reading level of materials try to find 
a readability formula in the language you are 
working with. The Fry Graph can be adapted to 
evaluate the reading level of Spanish materials. 

Also, materials that are technical and are written at 
a reading level higher than 10th grade may not need 
translation. People who read at that reading level in 
their own language are more likely to learn English 
at some time. Eventually they will be able to read 
these materials in English, making translations 
unnecessary. 



About the Translator 

Unfortunately, not everyone who belongs to the 
target group is a good translator. It is important that 
the person doing the translation be familiar with 
both the language and the culture of the target 
population. In addition, the translator should not 
only know English well, and be able to interpret it, 
but should also be able to write in the native 
language extremely well. A native person who is 
bilingual will be the most appropriate. If you do not 
have an appropriate staff member, hire one or hire 
a consultant to translate. When hiring a translator, 
it is helpful to ask an advisory group to review 
samples of the candidate's translated material. 

Changing the Format 

Sometimes, when translating from one language to 
another, the format changes. For example, the 
Spanish language uses more words than English to 
say the same thing; therefore, you will need more 
space on the page. Also, making materials 
culturally sensitive may change the layout of the 
material. 

Changing Illustrations 

In order to attract the target audience, the material 
must include pictures or illustrations showing 
people who resemble the target population. This 
will motivate people to read it. 

Proofreading 

The document must be checked for spelling, 
grammar, and accuracy of translation. Word 
processing programs in Spanish can help you with 
spelling and with some of the accents. Always give 
the material to others for review. Back translation 
is a method that will ensure that the translation is 
appropriate. Here, the translator writes the material 
in Spanish, trying to retain the main idea of the 
general content rather than the exact wording. Then 
another translator must translate this back into 
English to ensure that the material still has the 
original intent and message. 

Field Testing 

Always test your materials with the target 
population using the same principles of field testing. 



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List of Services Provided by the Latino Health 
Literacy Project 

The Latino Health Literacy Project, now in its fifth 
year, is offering the following services on a 
consultation basis: 

Translations 

Do you have materials written in English and want 
good-quality translation into Spanish? 
>" We can translate English materials that are already 
written at a sixth-grade reading level or lower. 

Simplifications 

Are the materials you want to have translated 
written at a reading level higher than sixth grade? 
>" We can simplify these materials in English before 
translating them into Spanish.. 

Review. Evaluation, and Revision of Spanish 
Translations 

Do you wonder if the Spanish materials you already 

have are accurate and culturally appropriate? 

>* We can review and/or revise materials for cultural 

sensitivity and for accuracy of content, spelling, 

and grammar. 

Materials Development in Spanish 

Do you have an idea or a health message but are 

unsure about how to produce materials that are easy 

to read and culturally effective? 

>' We can guide you in the development of your 
pamphlet, brochure, booklet, etc., from start to 
finish, or we can develop the materials for you. 

Field Testing of Materials 

Are you concerned about the educational message 

of your materials being clear or persuasive enough 

for your target audience? 

> We obtain valuable feedback from your target 
audience on content, graphics, cultural appeal, and 
attractiveness. This cost-saving evaluation step will 
enable you to make important revisions before you 
reproduce and distribute your material in its final 
form. 

Professional Training 

Do you need your staff (English or Spanish 
speakers) trained to be able to develop or translate 
materials into Spanish? 

>■ Ask for our presentation or training "Translating 
Across Cultures." 

Do you feel you need to learn aspects of the Latino 
culture to improve services and/or to provide more 
services that are well received? 



> We can help you learn how to provide more 
culturally sensitive services to Latinos by evaluating 
existing services and providing you with advice and 
recommendations for improvement and/or changes. 

> Program Development 

Do you need to develop a culturally appropriate and 
effective health education program for Latinos? 
>► We can help you from beginning to end by 

conducting one or all of the following steps in 

program development: 

• Identifying the educational needs of your target 
audience by conducting focus groups or surveys. 

• Developing a curriculum and/or a manual that is 
culturally targeted and that uses the principles of 
adult learning. 

• Training your staff to implement the program 
and to conduct health education in a dynamic 
and interactive way. 

• Conducting program evaluation for ftuther 
revisions and updating. 

Call us for a consultation! 



For more information on consultations, 

developing easy-to-read materials, field 

testing, workshops, and/or a catalogue of 

easy-to-read materials in Spanish or 

English, write or call: 

Aracely Resales, Director 

Latino Health Literacy Project 

Health Promotion Council 

of Southeastern PA, Inc. 

311 S. Juniper St., Suite 308 

Philadelphia, PA 19107 

(215) 546-1276 Fax (215) 545-1395 



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DIABETES EDUCATION FOR 

LATINOS: TRANSLATING 

ACROSS CULTURES 

Aracely Resales 

Latino Health Projects 

Health Promotion Council of Southeastern 

PA, Inc. 

ABSTRACT 

The Latino Health Project is taking the challenge to 
reach and educate Latinos about diabetes. The 
project conducts Spanish diabetes classes and 
develops and distributes easy-to-read health 
educational material for low-income, poor readers 
in its Latino community. Among Latinos in the 
United States, diabetes prevalence is increasing, 
particularly for indigent groups. In addition to a 
high prevalence of diabetes, 56% of Latinos are 
illiterate, making conventional diabetes education 
tools ineffective. 

A workshop shares strategies we have learned from 
adult educators and health educators. Participants 
learn ways of becoming knowledgeable about 
Latino target populations and are given a sense of 
why Latinos think their diabetes is not controllable. 
Techniques on how to incorporate these findings 
into practice to encourage behavior change are 
demonstrated. Effective teaching methods and 
materials are presented. 

Introduction 

Controlando Nuestra Diabetes^ (Taking Control of 
Our Diabetes) is a small-group education program 
started in 1994 by the Health Promotion Council, 
now located at two sites in Philadelphia. It 



"Controlando Nuestra Diabetes" was developed in 
consultation with Gail Thatcher, M.S.N., CDE, Diabetes Nurse 
Specialist for the City of Philadelphia. She is the State- 
authorized certifier for diabetes education programs. Major 
financial support came from the Pennsylvania Department of 
Health, with additional support from The Pew Charitable Trust, 
the Philadelphia Foundation, the Samuel S. Pels Fund, and the 
Philadelphia Department of Public Health. 



currently provides the at-risk underserved Latino 
community with comprehensive education and 
follow-up in diabetes. The goal of the program is to 
empower persons with diabetes with the ability to 
prevent or delay the complications of diabetes, 
including heart disease, neuropathy, renal disease, 
amputations, retinopathy, and stroke. 

Teaching methods are designed to give necessary 
information and to ensure participant understanding. 
Clients participate in programs that include a 
culturally sensitive nutrition and exercise 
intervention with a small-group format, as well as 
clinic-based and home visit follow-up. Cooking 
demonstrations and shared meals are part of each 
class. Community health educators assist with 
recruitment, assessment, and follow-up. 

The program requires a host primary care center to 
provide participant referrals; access to participant 
physicians, office and meeting space, kitchen 
facilities, and lab tests; and a cooperative follow-up 
arrangement. 

Program Description 

Controlando Nuestra Diabetes is an intensive, 
small-group approach to education. It assumes that 
one-time and/or relatively brief interactions between 
patients and providers is not sufficient time for 
understanding and communication to occur for 
either party. 

Controlando Nuestra Diabetes 

>- Allows time for patients and providers to know each 

other better. 
5> Provides adequate time for basic information about 

the disease to be explained. 
>> Provides a safe setting for patients and providers to 

exchange information on sensitive topics, for 

example, sexual impotence as it relates to the 

disease and medication side effects. 
>" Provides the time necessary for clarification and 

follow-up questions on technical aspects of diet, 

food preparation, medication, etc. 
> Encourages patient assertiveness in future 

interactions with physicians and other health 

professionals. 

Goal 

The goal of the program is to empower diabetics 
with the ability to prevent or delay the 
complications of diabetes— retinopathy, neuropathy, 
nephropathy, heart disease, and amputations— by 



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providing them with the needed education and 
understanding of the disease. 

All clients participate in a program that includes the 
following components: initial assessment and 
baseline measures, classes, and clinic-based follow- 
up. 

Baseline Assessments 

Upon entry into the program, all participants' 
baseline measures are taken — height, weight, blood 
pressure, medication history, and glycosylated 
hemoglobin. An initial interview is held to assess 
baseline knowledge, attitudes, and practices as well 
as the home environment. 

Following individual assessment, including a 48- 
hour dietary intake recall and review of the patient's 
calorie limit, the patient is assigned to a class. 

Classes 

Classes are a multifaceted intervention, involving 
modification of diet and exercise behaviors through 
demonstration, practice, feedback, and reward, 
taking into account culturally specific foods, values, 
and family patterns. A class usually consists of 8- 
12 persons, meeting weekly for 6 weeks. The 
seventh week is a graduation ceremony where 
participants receive a certificate along with some 
other small gifts. 

Curriculum and Handouts 

The program has a curriculum written in Spanish. 
This curriculum includes teaching information for 
each class. Each class session has specific and 
multiple leamer objectives. Classes related to food 
and nutrition include culturally appropriate names 
of foods that are locally and regionally available. 
Each participant receives a binder with Spanish 
handouts supplementing each class. These 
handouts have been translated, simplified, and 
tested with program participants. A set of more 
than 100 posters in Spanish is also available to be 
used as teaching aids. 

Class Content 

Sessions are approximately 3 hours long, including 
meal preparation and eating, and include at least 15 
minutes of physical activity. The following topics 
are covered in the curriculum: 

> What is Diabetes? 



>* Exercise and Self Blood-Glucose Monitoring 

>" Healthy Eating, Exchange List 

>* Reading Labels and Purchasing Food 

>- Managing Your Diabetes 

>► Taking Good Care of Yourself 

>* How to Test Your Blood Sugar 

>" Review and Graduation 

"controlando nuestra diabetes" list of 
Handouts 

>- Clase 1 

• Diario de la Comida 

• Almibar ("syrup") sin Azucar (Receta) 

• Alimentos Altos en Azucar 

• ^Que es la Diabetes? 

• Substitutos de Azucar 
5^ Clase 2 

• Otros Consejos para Hacer Ejercicio 

• Ideas para Hacer Ejercicios sin Riesgo 

• Programa para Caminar 

• Ideas para Caminar Mas y Mejor 

• Guia General para Ajustar la Comida Cuando 
Hace Ejercicio 

• Programa de Ejercicios de Calentamiento, 
Estiramiento y Enfriamiento 

• Ejercicios en la Silla 

• Examinandose el Nivel de Azucar en la Sangre 

• No Ponga Excusas para Hacer Ejercicio 
>- Clase 3 

• Los Seis Grupos de la Comida 

• El Colesterol 

• "Cuando Tenemos Diabetes. . . " Guia nutricional 
para diabeticos 

• Comiendo Saludablemente Usando los Seis 
Grupos de Alimentos para Personas con 
Diabetes (Lista de Intercambios) 

• El Plan de Comida para las Personas con 
Diabetes 

>► Clase 4 

• Alimentos Altos en Sal 

• Consejos para Comer Afiiera 

• "Libro de Recetas Puertorriquenas," Cocinando 
saludablemente 

>► Clase 5 

• Bajo Nivel de Azucar 

• Alto Nivel de Azucar 

• Que Hacer Cuando Esta Enfermo 

• Como Escoger Medicinas en la Farmacia o el 
Supermercado 

• Tipos de Insulina 

• Consejos para Volver a Usar las Jeringas 

• Agentes Orales (chart) 

• Pastillas para la Diabetes 



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Clase 6 

• Lidiando con la Tension 

• Problemas a Largo Plazo 

• Que Puede Hacer Usted para Ayudar a Prevenir 
Estos Problemas 

• ^Como Nos Afecta la Diabetes? 

• Cuidado de los Pies 

• Cuidados Generales para la Personas con 
Diabetes 

Clase 7 

• Pruebas Visuales 

• El Examen de la Orina 

• Evaluacion del Programa 



Clinic-Based Follow-up 

At this point participants 
questioned regarding: 



are interviewed and 



>- Frequency of blood-sugar monitoring 

> Any changes in self-care practices 

> Any hospitalizations and/or emergency room visits 
due to diabetes 

> Weight 

> Compliance with individualized meal plans and 
possible revisions 

>* Review of questions not answered on pre- and post- 
tests 

In addition, the following assessments are made: 



>- At 3 months 



>- At 6 months 



> At 9 months 



> At 1 Year 



Hemoglobin AiC or 
Glycosylated Hemoglobin, 
Fasting Blood Sugar, Blood 
Pressure, and Weight 
Total Liquid Profile, 
Hemoglobin A,C, Fasting 
Blood Sugar, Blood Pressure, 
and Weight 

Hemoglobin A,C, Fasting 
Blood Sugar, Blood Pressure, 
and Weight 

Lipid Profile, Hemoglobin 
A,C, Fasting Blood Sugar, 
Blood Pressure, and Weight. 
Repeat of interview and 
questioning conducted at 6- 
month intervals. 



Home-Based Follow-up 

Medical appointments and lab work are 
supplemented by regular home visits by a 
Community Health Worker (CHW). Program 
participants become acquainted with the CHW 
during the initial interview and class sessions. 



Follow-up home visits are scheduled 1 month after 
graduation. Home visit patterns and discharge 
criteria are determined based on the findings of a 
new acuity assessment tool. Additional home visits 
and telephone calls are made to participants who do 
not come to medical appointments. 

Home visits allow an assessment of the home 
environment, including the availability of facilities 
and equipment needed to prepare healthy food as 
well as the potential barriers to adherence to the 
diet/exercise regimens and glucose monitoring. 
Individualized visit plans include blood pressure 
measurement and education needed to support 
necessary diet and other behavior changes, 
including a 24-hour diet recall. In addition, the 
patient returns to the clinic at least every 3 months 
for weigh-in, blood pressure, glucose checks, lipid 
profile, and hemoglobin A,C. 

Using a CHW enhances the Taking Control Program 
in two ways. First, a CHW can carry out home visit 
follow-up, thereby reinforcing class instruction and 
supporting necessary diet and other behavior 
changes over time. Second, a CHW can 
significantly fi^ee up the time of the professional by 
assisting with participant recruitment and 
enrollment; administering baseline and follow-up 
assessment questionnaires; assisting with food 
procurement and preparation for classes; 
maintaining, coordinating, and implementing 
follow-up; and assisting with tickler files and 
recordkeeping. 

Findings 

We found that Latinos sometimes do not have an 
exact understanding of the doctor's instructions. 
They believe they are not receiving proper 
treatment. We heard the following comments: 
"Insulin or medication prescribed is not enough or 
is too much." "Medications don't work." Many 
think that diabetes is caused by stress, leading to the 
conclusion that "it doesn't matter what I do, my 
sugar will always stay high because I have too many 
problems." We also found that they know a lot 
about the disease and its complications. Most of 
them think that they are destined to suffer these 
complications sooner or later. "I know that I will 
end up, without one leg, like my grandmother." 
They feel they cannot exercise because they are not 



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used to doing it. "How can I start doing exercise 
(now that I am 45) if I have never exercised in my 
hfe?" 

The nutrition focus groups helped us find out what 
they eat, how they cook it, and where they buy their 
food. Many skip breakfast, others skip breakfast 
and lunch, although many eat something at 
midmoming and midaftemoon, and many feel they 
must eat a big dinner because of skipped meals. 
We also found that they know sugar is not good for 
diabetics, but many of them do not use sugar 
substitutes. ("Diet sugar produces cancer." "I don't 
know where to get it." "I can't afford it.") In our 
program, we show participants samples of sugar 
substitutes, let them taste and choose their favorite, 
and give them copies of the boxes of these products 
to take to the supermarket. The same should be 
done with any product you are trying to introduce. 

Translating AND Adapting Diabetes Programs 

Diabetes program coordinators and educators have 
to acknowledge the following: 

>* Diabetes education must be culturally appropriate. 
This way, people identify with it, the information is 
relevant, and participants are more likely and 
willing to accept the information. 

i'' There is diversity among people from the same 
cultural group. Differences include socioeconomic 
status, educational attainment, origin, age, and 
length of time in the United States. There are also 
cultural differences among cultural subgroups. 
Among Latinos, there are many subgroups in the 
United States — Mexicans, Cubans, Puerto Ricans, 
Colombians, Central Americans, South Americans, 
etc. Because of this, you must direct materials and 
programs to a specific subgroup, especially when 
teaching about food. It is important to use words 
and names of food that are familiar. 

>- Stories or testimonies given by community 
members can be very effective in encouraging 
others to participate in class. They can increase 
credibility, interest, and motivation. 

>" It is important to translate concepts into practice. 
Latinos with diabetes have stated that they know 
what they have to do but are frustrated by not 
knowing how to do it. Teaching general concepts is 
not enough. You must show them how to do these 
changes. For example, food preparation in class 
will help them learn how to effect behavior changes 
and food tasting will show them that properly 
prepared food still tastes good and that cooking 



with less salt, sugar, and fat is possible. Try to find 
out what foods they prefer to eat, what ingredients 
they use for cooking, and how to select foods they 
should eat. Use measuring cups and show how 
much is too much or too little. Make participants 
practice in class. Changes happen gradually, but 
you need to teach people where to start. 
>" Literacy is a problem across cultures. In the United 
States, 47% are fiinctionally illiterate and 37% 
speak a non-English language at home. In our 
program, we found that 5 out of 8 in the first group 
were ilUterate, 6 out of 12 in the second group, and 
4 out of 7 in the third group. Materials and 
handouts need to be written in a way that people can 
understand. All materials should be easy to read, 
with simple words, illustrations, well-organized 
information, no technical terms, and only three or 
four points at a time. Visual aids such as posters 
can be very effective, especially if they are matched 
with the handouts. 

> Exercise should be a part of every class. In our 
program, we practice step-by-step exercise for 10 
minutes before each class. 

>- Blood-glucose monitoring should also be an 
important part of class. We give participants a 
glucose monitor and practice in each class how to 
use it — how to test for blood sugar, how to keep 
records, and how to clean and maintain the monitor. 

> Empowerment is the most appropriate way to reach 
people with diabetes. These populations possess 
limited resources, have emotional, mental, and 
family problems, face language barriers, and may 
not have convenient access to health care. All of 
these do not motivate them to adopt or follow 
treatment. 

Recommendations on Developing Culturally 
Appropriate Diabetes Programs 

Do not try to reach everyone with the same 
message/strategy and expect it to work. First 
determine who is in your target group or population 
and assess their knowledge and misconceptions 
about diabetes. Find out where they go for care and 
what educational efforts have worked in the past, 
what have failed, and why. Then you can identify 
appropriate ways to motivate people to control their 
diabetes. Always be open to learning what their 
special educational needs are. 

How can you do this? We used needs assessment, 
advisory groups, and focus groups. A needs 
assessment can help determine the characteristics 
and attitudes of the target group, their demographics 



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(where they go for care, their origin/subgroup), and 
their educational needs. Advisory groups can help 
you revise materials and the curriculum. They can 
also help you in hiring the educator/translator. This 
is a key person. Besides knowing the language, this 
person should be part of the target group and 
familiar with available resources. He or she should 
be open-minded, familiar with the culture, willing 
to learn and be a part of the group, and sensitive 
and respectful to folk practices, cultural values, and 
beliefs. You will have to be flexible, perhaps hiring 
and training a person with a degree in education or 
a health-related field. You will also have to prepare 
the curriculum, revise all handouts, and supervise 
the educator regularly. Focus groups can help you 
learn why Latinos feel their diabetes is not 
controllable. We conducted two focus groups on 
diabetes, two on hypertension, and two on nutrition. 

Conclusion 

'>■ Every diabetes educator must bring knowledge to 
people in familiar and comfortable settings, address 
their immediate needs, stress psychological and 



psychosocial issues affecting their health, and, if 
possible, provide individual counseling follow-up 
and support. 
>* Diabetes education can be fim, especially if the 
whole family is included in classes and follow-up 
care. Plan interesting, dynamic, and realistic 
activities that will motivate behavioral change. 
Have a graduation and give incentives, such as a 
certificate of accomplishment and products that are 
good for their diet and health. The Health 
Promotion Council (HPC) is interested in expanding 
Controlando Nuestra Diabetes wherever possible. 
If your facility is interested in starting a program, 
call: 

> Aracely Resales 

Latino Health Projects 
Health Promotion Council of 

Southeastern PA, Inc. 
31 1 S. Juniper St. Room 308 
Philadelphia, PA 19107-5803 
Phone:(215)546-1276 
Fax: (215) 545-1395 
hlphpc@libertynet.org 



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NEW MEXICO PRIMARY CARE 

DIABETES MANAGEMENT 

PROGRAMS: A LAY HEALTH 

ADVISOR MODEL 

Judith S. Hurley, M.S., R.D. 

Katherine G. Bent, M.S.N., R.N. 

New Mexico Department of Healtli 



ABSTRACT 

This project provided preliminary evaluation of the 
efficacy of a primary care diabetes management 
model using lay health advisers (LHAs) to improve 
diabetes control and the health status of rural 
Hispanic and Native- American populations. 
Demonstration projects used Hispanic promotoras 
and a Navajo community health representative. 
Interventions included home visits, telephone 
support, classes, quality assurance, provider 
training, and case management. Pre- and post- 
quantitative evaluation addressed changes in 
glycosylated hemoglobin, body mass index, 
functional status, and standards of care. Qualitative 
evaluation was based on focus groups with clinic 
providers and interviews with lay health advisers, 
coordinators, and program participants. 
Preliminary analysis reveals improvements in 
functional status, glycemic control, and medical 
care. Final aggregate results and cross-site 
comparisons will be presented later. 

Project Objective 

The objective of this project is to improve self-care 
and clinic-based care in order to improve the 
quality of life and health outcomes in persons with 
diabetes. 

Venue 

The project used 4 rural, federally funded primary 
care clinic systems serving 33 communities (12 
clinic sites). Five clinics are in the New Mexico- 
Mexico border area; six clinics are in northern New 
Mexico; one clinic is in western New Mexico. 



Population Served 

Two-hundred fifty Hispanic and Navajo men and 
women age 35+ 

Program Services 

>■ Home-based and clinic -based diabetes education 

provided by lay health advisers and clinic 

professional staff; diabetes support groups; 

telephone support 
^^ Diabetes case management according to national 

standards of care (with some modifications by 

individual clinic systems) 
>► Quality improvement activities, including use of 

diabetes flowcharts, computerized case management 

systems, and provider inservices 

Time Period 

Three-year demonstration projects, July 1994- June 
1997 (This evaluation covers year 01, 1994-1995) 

Evaluation 

Quantitative 

Quantitative measures include pre- and 
postglycosylated hemoglobin to assess glycemic 
control; pre- and postbody mass index; pre- and 
postfunctional status assessment; and chart audits in 
all clinics to assess standards of care (participants 
vs. nonparticipants). 

Qualitative 

Qualitative measures include interviews with all lay 
health advisers (n=12); interviews with 13% of the 
program participants (n=33); focus groups with 
medical providers (one group held in each of the 
four clinic systems); and questionnaires completed 
by program coordinators (n=4). Results were 
coded, placed on matrices, and patterns, trends, and 
key issues identified. 

Conclusion 

Integration of lay health advisers into primary 
health care teams can help meet the significant 
challenges faced by providers and persons with 
diabetes in rural Hispanic and Native-American 
populations, improve health status, and reduce 
cultural and economic barriers to diabetes 
management. Maximizing the benefits of lay health 
advisers within a traditional, but changing, medical 
system requires significant attention to provider 
concerns, clinic infrastructure, staff communication 
issues, and lay health adviser training needs. 



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For Further Information 

Georgia Cleverley 

Program Manager/Project Director 

Diabetes Control Program 

New Mexico Department of Health 

P.O. Box 26110 

Santa Fe,NM 87502-61 10 

(505) 827-2953 

Key findings of the first year of the diabetes 
management program qualitative evaluation are 
presented below. 

Diabetes Management Programs Qualitative 
evaluation: lay health advisers 

>■ Ethnicity: 10 Hispanic 

1 Native American 
>> Gender: 1 male 

10 female 

> Age: 21-65 

3> Education: 9 high school/GED 

(3 have taken post-high 
school courses) 
ILPN 
1 graduate student 

Lay Health Advisers-. Perceptions Of Role 

>■ Teachers and advocates: provide iaformation 
about diet, exercise, concepts 

• More likely to do home visits 

> Logistical role: transportation, shopping, 
appointment reminders 

• Less likely to do home visits 

• More likely to meet client at clinic or by phone 

> Both Groups: Serve as interface between client 

and clinic providers. 

Lay Health Advisers-. Most Important 
Job Aspects 

> Help clients have better life through improved self- 
care and management of diabetes. 

> Advocate for client 

>► Motivate, encourage, support clients through 

• education 

• home visits 

• phone calls 

• group classes 

• reminders 



Lay Health Advisers-. Most Difficult Part 
Of Job 

>■ Logistical/managerial aspects 

• Not enough time 

• Form of payment (contract — taxes not taken 
out) 

• Finding clients' homes 

• Being prepared 

• Adequate educational materials 

> Discomfort dealing with clients' emotional needs 
>> Providers do not appreciate their work 

>> Supervisor holds them back 

LHA NEEDS 

> More training, more often, and earlier 

> Education regarding basic medical terms, diabetes 
management, communication, social and emotional 
issues 

> Referrals/promotion of program by providers 

Peer education/sharing 
More meetings with providers 
Office space, phones 
Directions to clients' homes 
Computer training 
Support to do more home visits 

POSITIVE Changes In Provider/Clinic Practices-. 
Provider Views 

> More frequent referral for foot exams, eye exams, 
renal screenings, glycohemoglobin 

> More client-oriented practices 

> Earlier identification of health problems through 
aggressive screening 

> More awareness of management issues and needs 

> Ability to prevent clients from "falling through the 
cracks" 

>► Time freed up due to LHA assistance 

Benefits To Client-. Provider Views 

> Increased client awareness 

> Decreased denial 

> Increased client motivation, enthusiasm, 
empowerment 

>- Less depressed, especially elderly 

> Improved client adherence to diet, exercise, and 
self-monitoring of blood-glucose 

> Filling prescriptions earlier, regularly 



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Lay Health ADVISERS: Provider Views 

> One-Clinic System: 

• LHAs should not be entrusted with client 
medical information 

• Do not know what they do — no communication 

• Not confident LHAs can be trained, even for 
dietary counseling tasks 

>" Three-Clinic Systems: 

• Valuable in providing community link between 
clinic and client 

• Valued for language capability and as 
community member 

• Can augment clinic tasks (e.g., appointment 
reminders) 

• Have unique counseling and support role for 
entire family 

• Develop concrete approaches to problem 
solving 

Challenges/Issues: Provider Views 

5> Client frustration when health does not 
improve 

> Many "not adhering to self-care regimens" 

• Lackofrefiigeration, phone, etc. 

• Geographical and social isolation 

• Family alcohol problems 

• Financial constraints 

> Some clients "falling through the cracks" 

• Poor program tracking 

• Poor follow-up 

• Lack of effective case management 

Overall Value Of Program To Clients 

>- 9 1 % felt program very valuable 

• Increased awareness and understanding of 
diabetes 

• Emphasized importance of diet, exercise, 
monitoring 

• Gave them a sense of sharing and support 

• Helped them to be motivated and positive 

• Helped them lose weight and lower blood sugar 

• Helped them feel increased energy and more in 
control of their diabetes 

Why Home Visits? The Clients Perspective 

> Changes clients attribute to home visits 

• Lowered blood-glucose levels 

• Weight loss 

• Dietary changes 

• Exercise during visit 

> Those who did not receive home visits 

• Expressed problems and concerns regarding 
♦ Self-monitoring of blood-glucose 



♦ Insulin injections 

♦ Nutritional information 
>► Why clients like home visits 

• Feel more relaxed, able to talk freely about 
health 

• Convenient, especially for those who live far 
from clinics or have no transportation 

• Native speaker helped them understand difficult 
concepts 

• Feel more emotionally supported than at clinics 

• Lay health advisers friendly and informative 

Diabetes Education Classes 

> 82% had attended classes 
>" 18% did not attend 

>* Barriers to attendance 

• Transportation ( 1 00% of those not attending) 

• Forgot about them (want reminders) 

Value Of Classes 

>' Of those who attended 

• 77% valued them highly 

• 19% valued them as somewhat helpful 

♦ Learned about diabetes 

♦ Liked social aspects 

♦ Valued information on diet, exercise, 
monitoring, foot care, and other topics 

♦ Many said they did not always follow 
advice 

> "I would have given up on self-care if it had not 
been for the program helping me overcome my 
discouragement." 

• 4% did not value them 

Support Groups 

>■ 72% attending support groups felt they were 
valuable 

• Liked hearing others' ideas 

• Felt less alone 

• Reason to get out of the house 

> 38% did not feel comfortable with the support group 
format 

>> Most of those who did not have support groups 
offered would like to attend them. 

Communication Issues 

> LHAs 

• Poor communication between lay health 
advisers and providers 

> Program Coordinators 

• Lack of support and participation by medical 
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• One-way communication from program 
coordinator to medical director 

>■ Providers 

• No communication (ignorant of program) 

• Issues regarding LHAs completing paperwork 

• Concerns regarding degree/quality of 
information they receive from LHAs 

Program Implementation Recommendation 

> Provider involvement in earliest planning stages 



Discussion and delineation of LHA, coordinator, 

provider, and clerical staff roles; put in writing 

4-6 month start-up period 

Careftil LHA recruitment/hiring 

Minimum 3-day diabetes content training for LHAs 

prior to client contact 

Active supervision/mentoring of LHAs 

Ongoing provider education/activities/ 

communication 



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THE PREVALENCE OF 

PHYSICAL EXERCISE AND 

DIABETES IN A SAMPLE 

POPULATION OF 

MONTERREY, NUEVO LEON 

PREVALENCIA DEL EJERCICIO 

FiSICO Y DIABETES EN UNA 

MUESTRA DE POBLACION DE 

MONTERREY 

Ruby M. Vargas Arriaga, M.S.P. 
Institute de Seguridad y Servicios 

Sociales 

para los trabajadores del Estado 

(I.S.S.S.T.E.) 

ABSTRACT 

The objective of this investigation was to learn 
about the frequency and characteristics of physical 
exercise as part of the integral control of diabetes 
mellitus. It was conducted with a random sample 
of the population in a residential area of Federal 
employees; 341 persons older than 20 years of age 
were visited in their homes. The prevalence of 
diabetes was 14% more frequent in women than in 
men. One hundred and twenty-three persons 
exercised regularly, 21% of the total. Among the 
diabetics, only 4.2% exercised. The results of the 
statistical analysis indicated that exercise sfrongly 
influences the presence of the disease. The 
frequency of the studied variable was lower than 
expected by 10, leading to the conclusion that it is 
necessary to promote, expand, and organize 
educational activities that include exercise as part 
of the adequate control of diabetes. 

INTRODUCOON 
La Diabetes 
La Diabetes es una enfermedad muy importante por 
su magnitud elevada, que en encuestas publicadas 
en Nuevo Leon, Mexico, demuestran que mas de un 
10% de la poblacion adulta la padece.' En Estados 
Unidos se considera que la Diabetes Tipo II afecta 
de 10 a 12 millones de americanos mayores de 20 



anos.^ Tambien es importante por su incidencia en 
aumento, alta mortalidad, importante causa de 
hospitalizaciones, motivos de consulta, 
incapacidades e invalideces. 

Existen actualmente numerosas medidas para el 
control y tratamiento adecuados que permiten al 
paciente llevar una vida practicamente normal y 
vivir muchos anos. Sin embargo, este control no se 
consigue unicamente con una receta del medico, 
sino que • incluye variados elementos como: ' 
educacion continua, dieta, ejercicio fisico, higiene 
especifica, control de medicamentos y prevencion 
de complicaciones, requiriendo la participacion de 
todo un equipo de salud formado por: educadores, 
nutricionistas, entrenadores en ejercicio, 
trabajadores sociales, enfermeras y personal de 
psicologia. 

El ejercicio es importante para toda la gente, scan o 
no diabeticas,^ porque mejora la aptitud fisica, 
reduce el riesgo de presentar enfermedades del 
corazon y presion arterial alta, y mejora la 
circulaci6n sanguinea. Ayuda a disminuir el 
sobrepeso y mantener el peso ideal. Produce 
beneficios psicologicos, da energia, ayuda a 
controlar y disminuir la tension nerviosa, la 
ansiedad, la depresion, el insomnio, y aumenta la 
resistencia a la fatiga fisica y mental. 

En la relacion del ejercicio con la diabetes, el 
concepto de que la actividad fisica beneficia a los 
pacientes con diabetes mellitus tiene cientos de 
afios; sin embargo, a traves de ese tiempo ha habido 
controversias y en algunos casos fue contraindicado. 
Despues del descubrimiento de la insulina, el 
ejercicio volvio a tener popularidad para el 
tratamiento de la diabetes por Joslin y Katsch, que 
lo incluyen como una de las tres partes basicas de la 
terapia, junto con dieta e insulina.^ 

En los ultimos anos ha resurgido el interes en las 
interacciones de ejercicio, entrenamiento y situacion 
diabetica. Obviamente los efectos del ejercicio 
difieren en los subgrupos de pacientes, scan del 
Tipo I o del II, asi como el estado de su control 
metabolico. 

Podemos recordar que la Diabetes Tipo I es una 
enfermedad autoinmune, caracterizada por insulitis 
linfocitica, con una destruccion selectiva, mediada, 



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autoinmime de las celulas beta del pancreas, que 
producer! la insulina; tienen una anormal, pero 
relativamente buena secrecion de insulina y 
complicaciones relacionadas con el control 
adecuado de su glucosa. Esta asociada con un alto 
riesgo de enfermedad cronica del corazon, 
enfermedad vascular periferica, nefropatia y 
ceguera. Como factores predisponentes senalan: 
obesidad, edad y antecedentes familiares de 
diabetes. Como factores de riesgo se incluyen: 
hipertension arterial e hiperlipidemia. 

El uso del ejercicio como terapia en la Diabetes 
Tipo I ha demostrado que un ejercicio regular 
puede alterar el estado inmunologico y proteger 
parcialmente de la destruccion de los tejidos. Las 
celulas beta en personas entrenadas presentan una 
baja actividad metabolica y son menos susceptibles 
al ataque inmune. Tambien se ha observado que el 
ejercicio disminuye la concentracion de glucosa en 
plasma en personas con un buen control de Diabetes 
Tipo I. 

El ejercicio regular, cuando hay deficiencia de 
celulas beta, incrementa la capacidad secretoria de 
las celulas remanentes y tambien reduce la 
severidad de la hiperglucemia. El uso del ejercicio 
ayuda a disminuir los requerimientos de insulina, 
aumenta la eficiencia del sistema cardiovascular, e 
incrementa los capilares y el numero de 
mitocondrias en el musculo esqueletico activado. 
Tambien aumenta el numero de receptores a la 
insulina y la sensibilidad a la insulina. Ayuda a un 
mejor control de las glucemias. Previene la 
ateroesclerosis prematura (a los 30 a. asociada con 
la enfermedad renal) y tiene influencia sobre los 
factores de riesgo de esta como: hiperlipidemia, 
coagulacion anormal e hiperinsulinemia. Uno de 
los mayores riesgos en este tipo de diabetes, durante 
el ejercicio, es la hipoglucemia. 

Prevenoon De Hipoglucemia Durante Y Despues 
Del Ejercicio 

>■ Consuma carbohidratos (15-30 gr.) por cada 30 
min. de ejercicio de moderada intensidad. 

>* Consuma un snack de carbohidratos que se 
absorban lentamente despues de sesiones 
prolongadas de ejercicio. 

>- Disminuya la dosis de insulina. 

^^ No ejercite el musculo donde se inyecto insulina al 



menos por una hora. 
>* No haga ejercicio por las tardes. 

En la Diabetes Tipo II, el ejercicio a corto plazo 
puede bajar los niveles de glucosa en la sangre, y a 
largo plazo puede reducir los requerimientos de 
medicamentos. Durante el ejercicio moderado, 
primeramente se utiliza la glucosa almacenada en 
los miisculos, despues estos empiezan a utilizar la 
glucosa de la sangre, disminuyendo en forma 
gradual el nivel de glucosa en la sangre; incluso 
despues del ejercicio, la glucosa en sangre continiia 
disminuyendo conforme el musculo se va 
reabasteciendo de glucosa. 

Tambien aumenta la respuesta a la insulina por los 
receptores de esta y ayuda a un mejor control de la 
enfermedad al hacer que las celulas del organismo 
respondan a la insulina en forma continua, evitando 
oscilaciones bruscas de la glucosa en la sangre. 

Recomendaciones De Ejercicio En Paoentes 

Con Una Larga Evoluci6n De Diabetes Tipo I 

>* Tipo: Aerobico 

Duracion: 20-40 min. 
Frecuencia: 4 a 6 dias por semana 
Intensidad: 50-60% vo2 MAX 
T.A.S.: 180-200 mm/hg. 

Muchos estudios de investigacion ban demostrado 
que la actividad fisica no solo sirve para el control 
de la diabetes, junto con la dieta y la reduccion de 
peso, sino que tambien es importante en la 
prevencion de Diabetes Tipo n, independientemente 
de los factores de riesgo de la enfermedad.^ 

En ellos se ha mencionado: 

> Que las sociedades que tienen mas actividad fisica, 

tienen menos diabetes que aquellas que son 

sedentarias. 
>- La actividad fisica incrementa, ademas, la 

sensibilidad a la insulina. 
>" Los programas regulares de ejercicio producen 

perdida de peso e incrementan la tolerancia a la 

glucosa. 

En la Universidad de Pensilvania se estudiaron 
5,990 hombres,* 202 de los cuales desarroUaron 
diabetes de 1962 a 1976; en ellos se demostro que la 
incidencia de diabetes disminuyo a medida que se 
incrementaba el gasto de calorias por el ejercicio. 
Por cada 2000 calorias gastadas, el riesgo de 



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diabetes se redujo en un 24%. Se concluyo que el 
incremento en los niveles de actividad fisica es 
efectivo para prevenir la diabetes II, y que la 
proteccion es mas alta en individuos que tienen 
factores de riesgo para la enfermedad. 

El ejercicio tiene mucho valor tambien como 
antidepresivo: multiples estudios han demostrado 
la eficacia del ejercicio en el tratamiento de la 
depresion, el efecto del ejercicio aerobico segun 
GREIST^ file el mismo que en pacientes tratados 
con medicamentos o con psicoterapia de grupo. 
Martinson y North* concluyeron que en todas las 
formas de depresion, incluyendo los desordenes 
depresivos mayores o menores, depresion primaria 
y secundaria, hubo respuesta a los programas de 
ejercicio a la 24a. semana. El ejercicio combinado 
con psicoterapia produce un efecto que excede al 
del ejercicio solo, o el de la psicoterapia sola. 

En nuestro medio, podriamos considerar a nuestra 
poblacion como sedentaria, pues de la poblacion en 
general, se considera que solo de un 10 a 20% de la 
gente adulta hace ejercicio en forma regular,^ este 
lo realiza mas frecuentemente los hombres que las 
mujeres, lo cual se relaciona tambien con las altas 
prevalencias de obesidad e hipertension arterial, 
asociandose la obesidad a la diabetes hasta en un 
80%. A nivel local, se efectuo un estudio en el que 
se aplicaron 612 encuestas a trabaj adores de 27 
oficinas correspondientes a Secretarias Federales, la 
mayoria del sexo masculino, de los cuales el 45% 
contesto que hacian ejercicio, pero solamente un 
54% lo efectuaban con frecuencia, intensidad y 
duracion necesaria para considerarlo adecuado. El 
80% pertenecen a edades jovenes, menores de 39 
anos. Por lo anterior podemos elaborar la hipotesis 
de que si la frecuencia de ejercicio es baja en la 
poblacion en general, es mas baja aiin en la 
poblacion diabetica. 

Objetivo General: 

Determinar la frecuencia de la practica del ejercicio 
fisico como parte del control de la Diabetes 
Mellitus Tipo II, en una muestra aleatoria de 
poblacion de Monterrey, N. L. 

OBJETIVOS INTERMEDIOS: 

>■ Determinar la prevalencia de Diabetes Mellitus en 
una muestra de poblacion. 



Lugar: 



>" Describir y analizar la distribucion de la enfermedad 

por grupos de edad y sexo. 
>* Analizar la practica del ejercicio segun diagnosticos 

y sus caracteristicas en la poblacion estudiada 

MaterialesY Metodos 

>■ Universo de estudio: Personas mayores de 20 

aiios, de ambos sexos, 
habitantes de la colonia 
Burocratas Federales. 
Colonia Burocratas 

Federales, habitada por* 
empleados federales, situada 
al noreste de la ciudad de 
Monterrey. 

Dejuniode 1989 a 1990. 
En el area mencionada se 
localizaron 720 familias con 
un total de 3,465 personas, 
de las cuales 1,918 fueron 
mayores de 20 aiios. 

Se calculo la muestra para diabetes mediante la 
formula: 



>► Tiempo: 
>* Muestra: 



n = 


E 


n = 


2r.05V.95^ 
(.0002) 


n = 


4C.05V.95)- 1900 = 475 
.0004 4 


n'= 


475 = 381 
1+475 
1918 



n = Tamafio de la muestra. z = 95% de 
confiabilidad. p = Porcentaje estimado de 
diabeticos. q = Proporcion de la poblacion no 
enferma. e = Error aceptable de estimacion .02% 

Se obtuvo una muestra para diabetes de 381 
personas, calculando un 5% de diabeticos segun la 
bibliografia utilizada. Se aplico un cuestionario 
precodificado en el domicilio de las personas, a 
todos los sujetos mayores de 20 afios presentes 
durante la entrevista, mediante el procedimiento de 
muestreo aleatorio con seleccion sistematica de 



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viviendas (una de cada 2.4 viviendas para 
encuestas). 

Hubo un alto grado de ausentismo en las viviendas 
(30%) mayor para el sexo masculino. La glucosa se 
midio por el examen de determinacion de esta en 
tirillas reactivas, los resultados sospechosos se 
enviaron al laboratorio del Hospital Regional 
situado en la misma colonia. Individuos con mas 
de 140 mg. de glucosa en la sangre en dos 
examenes se consideraron diabeticos aiin en 
ausencia de sintomas.* 

Definicion de ejercicio: Estimacion global de 
energia utilizada para una actividad fisica, de 
frecuencia, intensidad y duracion suficiente para 
considerarla efectiva, no importando el tipo.' 

Resultados 

587 personas contestaron la encuesta sobre el 
ejercicio, pero solo 341 acudieron al laboratorio del 
Hospital Regional a completar sus pruebas de 
glucosa en sangre. De la muestra de diabetes que 
file de 381 personas, se obtuvo un 90% del total de 
muestras. 

La distribucion por grupos de edad y sexo de los 
individuos encuestados (cuadro numero 1), mostro 
un predominio del grupo de edad de 30 a 39 anos, 
con un 27.6%), siguiendo el grupo de 20 a 29 anos 
con un 24.5%, y luego el de 40 a 49 afios, con un 
20% del total. 

La mediana fue de 38 aiios, y la media de 41 anos. 
El 73%) de las personas encuestadas flieron mujeres, 
y el 26% hombres. 

Se obtuvo una tasa de prevalencia de diabetes de 
14.07 (cuadro numero 2). 

Se detectaron 16 casos nuevos de diabetes (cuadro 
numero 3). Con diabetes e hipertension 14 casos, 
diabetes y obesidad 10 casos, y con las tres 
enfermedades— diabetes, hipertension y 

obesidad— hubo 8 casos, detectandose un total de 48 
casos. 

Respecto a la prevalencia por grupo de edades 
(cuadro numero 4), para diabetes, el grupo de 50 a 
59 aiios tuvo la tasa mas alta, siguiendo el de 40 a 
49 anos con tasa de 15.9, y luego el de 60 a 69 aiios, 
con una tasa de 25.7. 



De 387 personas que contestaron si practicaban 
algun tipo de ejercicio o no, 123 hacian ejercicio 
fisico con 20.9%) del total (cuadro numero 5) y 464 
no, con un 78.7%. 

En el grupo de personas que padecian alguna 
enfermedad como hipertension arterial y obesidad, 
el 13.3%) hacian ejercicio y el 86.6%) no. 

En las personas diabeticas, 2 de 45 hacian ejercicio 
con un 4.2% y 96%) no practicaban ningun tipo de 
actividad fisica. 

El valor de chi cuadrada fue de 22.51 con un nivel 
de significancia de 0.0005, por lo que se rechazo la 
hipotesis de que el ejercicio no influye, y se acepto 
que si influye en la presentacion de las 
enfermedades estudiadas, y hay una dependencia 
entre las 2 variaciones: diabetes y ejercicio. 

Tambien se obtuvo que en los casos de diabetes, la 
frecuencia observada de ejercicio fue muy inferior 
a la frecuencia esperada; la frecuencia observada fue 
de 2, y la frecuencia esperada era de 16. 

De las personas que hacian ejercicio, el 58%) lo 
hacian con la frecuencia, intensidad y duracion 
aceptables (cuadro numero 6), y solo el 25% no 
tenian un aprovechamiento importante, porque lo 
efectuaban una vez por semana. 

Cuadro No. 1 

Determinaci6n por grupos de edad v sexo de la 



Doblaci6n 


estudiada 








Grupo de 
Edad 


Sexo 
Masculino 






Pnr 


Sexo 
Femenino 




Total 


Ciento 


20-39 afios 


25 


59 


84 


25 


30-39 afios 


21 


73 


94 


28 


40-49 afios 


16 


53 


69 


20 


50-59 afios 


10 


32 


42 


12 


60-69 afios 


12 


12 


35 


10 


70 y mas 


7 


10 


17 


5 


TOTAL 


91 


250 


341 


100 



Fuente: Observacion directa 



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CUADRO No. 2 

Prevalencia de diabetes 

Col. Bur6cratas Federales I.S.S.S.T.E.. N.L. 



Personas examinadas 



Niimero de casos 



Tasa de prevalencia 



341 



48 



14.07 



CUADRO No. 3 

Casos de diabetes v sus asociaciones con otros 
padecimientos 



Casos nuevos de diabetes 


16 


Diabetes e hipertension 


14 


Diabetes y obesidad 


10 


Diabetes, hipertension y 
obesidad 


8 


TOTAL 


48 



CUADRO No. 4 



Grupo De Edad 


Tasa 




20-39 aiios 


1.3 




30-39 anos 


2.9 




40-49 afios 


8.8 




50-59 anos 


22.3 


.- 


60-69 aiios 


14.5 




70 y mas 


12.9 





El mayor porcentaje de mujeres (73%) y la baja 
proporcion de hombres que se pudieron encuestar, 
coincide con otros estudios similares. Al efectuar la 
visita domiciliaria, la mayoria de los hombres 
estaban en sus trabajos. 

La prevalencia de diabetes del 14% fue muy 
superior a la que se estimo inicialmente de 2 a 5%; 
sin embargo, tambien coincide, aunque ligeramente 
superior, con la obtenida en otras encuestas locales, 
una en el municipio de Guadalupe, en muestra 
representativa de 1,124 individuos, que fue de 10%, 
y otra de 2000 personas en el Centro de Deteccion 
de Diabetes del Hospital Universitario de 
Monterrey, que fue de 8.2%). 



CUADRO No. 5 

Practica de ejercicio fisico segun diagn6sticos. Col. Bur6cratas Federales LS.S.S.T.E.. N. L . 



Hacen 
Ejercicio 


Diabetes 


Hipertension 


Obesidad 


Sanos 


Total 


% 


si 


2 


25 


7 


89 


123 


20.9 


NO 


45 


99 


76 


244 


464 


78.9 


TOTAL 


47 


124 


83 


333 


587 


100 



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\ 



CUADRO No. 6 

Frecuencia por semana de la prdctica de eiercicio fisico 



de la poblaci6n estudiada 

Col. Bur6cratas Federales I.S.S.S.T.E., N.L. 


Frecuettcia 


NiSmero 


Poreiento 


Una vez por semana 


33 


25 


Dos veces por 
semana 


21 


16 


Tres veces por 
semana 


41 


'31 


Seis veces por 
semana 


35 


27 


No hacen ejercicio 


484 


78.7 


TOTAL 


615 


100 



Fuente: Observacion directa 

DISCUSION 

La distribucion de la poblacion objeto de este 
estudio por grupos de edad, muestra una poblacion 
mas numerosa en el gmpo de 30-39 anos, lo cual es 
importante porque este numeroso grupo pasara en 
diez anos mas al grupo de mayor riesgo para 
enfermar, que se inicia desde los cuarenta anos de 
edad. 

El bajo niimero de casos nuevos detectados de 
diabetes se podria explicar por el funcionamiento de 
un programa permanente de deteccion en la 
institucion donde se atienden las personas 
encuestadas (I.S.S.S.T.E.), al cual ya han acudido la 
mayoria de las personas. 

Respecto al antecedente de ejercicio fisico, se 
observe en el grupo total una incidencia baja en esta 
actividad; solo el 21% hacian ejercicio. Solo dos 
diabeticos de 47 hacian ejercicio en forma regular, 
con una tasa de prevalencia de 4.2%. No se 
localizaron estudios locales ni nacionales para 
comparar estos datos, pero debido a la baja 
frecuencia de poblacion que practica la actividad 
fisica, era de esperarse que los diabeticos 
presentaran una incidencia mas baja de ejercicio que 
la poblacion general. 

La frecuencia observada de ejercicio frie muy 
inferior a la esperada. 



En el analisis estadistico del grupo total se aplico la 
prueba de chi cuadrada (X^), la cual fue de 22.5 con 
un nivel de significancia de 0.0005, lo que 
demostro una dependencia muy frierte enfre las dos 
variables: enfermedad y ejercicio, aceptandose la 
hipotesis altemativa de que el ejercicio es una 
variable que influye fuertemente en la presentacion 
de la enfermedad. 

CONCLUSIONES Y RECOMENDAOONES 
La realizacion de ejercicio como parte de la terapia 
en el confrol de la glucosa en los diabeticos es 
demasiada baja en la poblacion que se estudio, por 
lo que es obvio que esta siendo subutilizado como 
modalidad terapeutica. Por lo anterior, es necesario 
promover programas educativos y uAa apropiada 
supervision para que el ejercicio se haga en 
condiciones de seguridad y eficiencia. 

Se recomienda el ejercicio moderado, de tipo 
recreativo para que tenga la menor cantidad de 
efectos colaterales. 

Los ejercicios que se recomiendan son los 
aerobicos: caminar, correr, nadar y bicicleta. 
Aunque recientemente se ha demostrado que el 
ejercicio anaerobico de alta resistencia puede 
resultar benefico en personas no diabeticas. Estos 
ejercicios en diabeticos pueden resultar en un 
aumento de la tension arterial sistolica y causar un 
detrimento en los cambios hemodinamicos, por lo 
que no se recomienda en pacientes de edad 
avanzada. 

Algunos deportes competitivos como racketball, 
basquetbol y tenis pueden ser peligrosos, y en 
pacientes con retinopatia incipiente, deberan usar 
proteccion para los ojos con el riesgo de trauma. 

Antes de la sesion de ejercicios, deberan hacer un 
calentamiento de 5 a 10 minutos, seguido de 
estiramientos suaves de los miisculos para prevenir 
lesiones. 

Despues de finalizar la sesion, se aconseja un 
enfriamiento similar para evitar el riesgo de 
arritmia y facilitar una rapida recuperacion de la 
fatiga. 

Se recomienda una duracion de 20-40 minutos, con 
una frecuencia de 4 a 6 dias a la semana, y una 
intensidad de 50-60% de vo2 maximo. 



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Las tablas de maxima frecuencia cardiaca que se 
usan en los no diabeticos deberan ser usadas con 
mucha precaucion en pacientes que tienen diabetes 
de larga duracion. 

Debido a los efectos transitorios en la disposicion de 
glucosa durante el ejercicio, es mejor hacer ejercicio 
en la manana temprano antes del desayuno. 

Los efectos hipoglucemicos despues del ejercicio 
son menos severos durante la mailana. El ejercicio 
en la tarde produce hipoglucemia mas pronunciada 
y pueden ocurrir crisis hipoglucemicas durante el 
sueiio. 

Motivacion: Para que una poblacion se inicie en la 
practica del ejercicio, se deben utilizar las tecnicas 
variadas de motivacion, ofrecer actividades 



deportivas con las que el paciente disfrute, 
proporcionarle una amplia variedad de ejercicios, 
promover que participe en actividades deportivas de 
equipo, y que la familia y los amigos lo estimulen, 
lo acompaiien y lo animen a salir adelante. 

Es importante iniciar el ejercicio lentamente, con 
una progresion gradual, y desde luego, no plantearse 
metas poco alcanzables. La practica del ejercicio 
como medicina preventiva y de control no tiene un 
costo; es gratuito y le ahorraria mucho dinero y 
sufrimiento tanto al paciente como a las 
instituciones de salud que atienden a diabeticos. 

El resultado final para el paciente sera: aumentar la 
autoestima, mejorar la calidad de vida y disminuir 
riesgos de enfermedades vasculares. 



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H 



BIBLIOGRAFIA 



1. Vargas A. Ruby. Prevalencia de Obesidad, 
Hipertension y Diabetes en ima muestra de poblacion 
urbana del I.S.S.S.T.E. de N. L., Border Health . 
P.A.H.O. Vol. VI-2:2-10. 1990. 

2. National Diabetes Data Group. Diabetes in America . 
U. S. Dept. of Health and Human Services. Pub. 
85:1468. 1985. 

3. Vitug A, Schneider S. Exercise and type I Diabetes 
MeUitus. Exercise and Sports Sciences Reviews . 16:285- 
300. 19.80. 

4. Noble DJ, Farrell P. Effect of Exercise Training on 
the Onset of Type I Diabetes in the B.B.AV rat. Med. Sci. 
Sports Exercises . 26:9. 1130. 1994. 

5. Heimlich S, Rangland D, Paffenbarger R. Prevention 
of no insulin dependent Diabetes MeUitus with Physical 
Activity. Med. Sci. Sports Exercise . 26-7:824-836. 
1994. 

6. Duim A, Dishman A. Exercise and the Neurobiology 
of Depression. Exercise and Sports Sciences Reviews . 
19:41-83. 1991. 

7. Vargas R. Medicina Preventiva en lugares de trabajo. 
Memorias. XXVII. Reunion Annual de la Sociedad de 
SaludPubhca. Pag. 35. Guanajuato, Gto., Mexico, 1983. 

8. National Diabetes Data Group. Diabetes in America . 
National Institute of Arthritis, Diabetes and Digestive and 
Kidney Diseases. Pub. No. 85:1470. 1985. 

9. Caspersen CJ, Powell K, Christenson G. Physical 
Activity, Exercise, and Physical Fitness. Definitions and 
Distinctions for Health Related Research. Pub. Health 
Rep . 100:125-130. 1985. 

10. Caspersen CJ, Powell K, Christenson G. Physical 
Activity, Exercise, and Physical Fitness. Definitions and 



Distinctions for Health Related Research. Pub. Health 
Rep. 100:125-130. 1985. 

1 1 . Dunn A, Dishman A. Exercise and the Neurobiology 
of Depression. Exercise and Sports Sciences Reviews . 
19:41-83. 1991. 

12. Helmrich S, Rangland D, Paffenbarger R. Prevention 
of no insulin dependent Diabetes MeUitus with Physical 
Activity. Med. Sci. Sports Exercise . 26-7:824-836. 
1994. 

13. National Diabetes Data Group. Diabetes in America . 
U. S. Dept. of Health and Human Services. Pub. 
85:1468. 1985. 

14. National Diabetes Data Group. Diabetes in America . 
National Institute of Arthritis, Diabetes and Digestive and 
Kidney Diseases. Pub. No. 85:1470. 1985. 

15. Noble D J, Farrell P. Effect of Exercise Training on 
the Onset of Type I Diabetes in the B.B.AV rat. Med. Sci. 
Sports Exercises . 26:9. 1130. 1994. 

16. Vargas A. Ruby. Prevalencia de Obesidad, 
Hipertension y Diabetes en una muestta de poblacion 
urbana del I.S.S.S.T.E. de N. L., Border Health. 
P.A.H.O. Vol. VI-2:2-10. 1990. 

17. Vargas R. Medicina Preventiva en lugares de 
trabajo. Memorias. XXVII. Reunion Anual de la 
Sociedad de Salud Piiblica. Pag. 35. Guanajuato, Gto., 
Mexico, 1983. 

18. Vitug A, Schneider S. Exercise and type I Diabetes 
MeUitus. Exercise and Sports Sciences Reviews . 16:285- 
300. 1980. 



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MENTAL HEALTH 



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1 



TRANSFORMING COMMUNITY 

HEALTHCARE: IMPACT OF 

DEPRESSION AND DISTRESS 

ON SOMATIC COMPLAINTS OF 

THE DISTRESSED LATINA 

Deborah Guadalupe Duran, Ph.D. 
University of Denver 

ABSTRACT 

The purpose of this study was to examine the 
changing role of depression in the manifestation of 
low-level, chronic, unspecified health problems of 
the Latina at various acculturation levels. The 
research team collected data fi-om 13 health care 
and mental health facilities in the Denver metro 
area and the Alamosa Valley. Trained data 
collectors distributed questionnaires and conducted 
interviews with Hispanic women and their 
providers. Regressions, structural equation 
modeling, and multivariate analyses were 
conducted to explore the various relationships of 
demographics, depression, health problems, 
treatment, acculturation level, and distressors. 

There are inter- and intracultural differences 
concerning the influence of depression on the 
manifestation of somatic complaints. Depression is 
not an indicative factor for somatic complaints of 
low-acculturated Latinas; thus, antidepressants may 
not be needed to treat somatization of these 
patients. The insignificance of depression 
facilitates the cultural coding that somatization is a 
modality to elicit support. A further interpretation 
of these results acknowledges the use of somatic 
complaints to manage distress. Models of 
culturally appropriate support and care should be 
explored to reduce distress and somatic complaints. 



Note: The material in this document is copyrighted. 
Obtain permission from the author to reproduce. 



Summary 

A well-documented problem in many health care 
settings is the overutilization of services by 
individuals who are healthy from a medical 
standpoint. Katon (1982) has estimated that 25 to 
75% of all clients using primary care clinics are 
somaticizers (4-6 complaints) with Latinas being the 
most likely population group to be diagnosed as 
such. Although individuals with somatic complaints 
may be healthy from a physiological standpoint, 
they have been associated with suffering from 
depression and other psychological problems 
resulting from stress. 

Generally, conventional health care facilities are 
unable to treat these individuals appropriately. 
Typical ways of managing patients with somatic 
complaints have been to spend less time with them, 
to reassure them that they are not sick, to administer 
placebos, and to prescribe antidepressants. 
However, these approaches are seldom effective 
because they fail to address the real issues 
underlying the complaints, thereby compelling the 
patient to continue fi-equent utilization of health care 
services. 

This study examined depression, cultural 
determinants, psychosocial factors, and 
patient/provider relationships relative to the level of 
acculturation of the distressed Latina. Insight is 
provided for understanding the components that can 
be addressed in rendering more appropriate health 
care and for identifying special needs that can be 
distinguished as a means to reduce the utilization of 
health care facilities. 

For Hispanics, using somatic complaints is a 
cultural modality to elicit support when distressed. 
It is not a psychological disorder associated with 
depression as defined by the European-American 
culture. However, the influence of the dominant 
culture on the Latina in the United States determines 
the treatment received and denotes the presumed 
factors that contribute to the somatic complaint 
onset. Thus, the care provided may not be culturally 
appropriate and, as a consequence, does not reduce 
the utilization of medical services by the Latina. 
This phenomenon may be due to the Latina' s 
augmenting factors, as well as the function of 



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somatic complaints that are not always similar in 
their predispositions cross-culturally. 

Regardless of acculturation levels, there appeared to 
be a transgenerational influence on this particular 
cultural coding to manage distress. Young and 
elderly seemed more likely to use this modality to 
elicit support. Thus, understanding and 

acknowledging inter- and intracultural differences 
becomes imperative to provide appropriate care to 
the Latina with somatic complaints, and to reduce 
the overutilization of health care services. 

Method 

The research team collected data from 13 health 
care and mental health facilities in the Denver 
metro area and the Alamosa Valley. Trained data 
collectors distributed questionnaires and conducted 
interviews with 465 self-identified Hispanic women 
and their care providers. This report summarizes 
findings in two major areas: 1) the role of 
depression and 2) the association of distress and 
somatic complaints. 

Subjects 



• Some trade school 

• Trade school cert. 



2% 
3% 



Ethnicity (self-identified) 




• Mexican 


38.0% 


• Puerto Rican 


00.5% 


• Cuban 


00.2% 


• Latina 


00.4% 


• Chicana 


30.0% 


• Latin-American 


00.8% 


• Hispanic 


00.6% 


• Spanish 


00.2% 


• Mixed (half) 


00.7% 


Income (self-identified) 




• 0- $5,000 


57% 


• $5 - 10,000 


18% 


• $10-15,000 


10% 


• $15,000+ 


15% 


Education (self-identified) 




• Fourth grade 


3% 


• Sixth grade 


6% 


• Junior High 


13% 


• Some high school 


23% 


• High School 


20% 


• GED 


9% 


• Some college 


13% 


• AA degree 


4% 


• BA/BS degree 


3% 


• Graduate degree 


1% 



Procedure 

Subjects waiting for health care appointments were 
asked by trained research assistants to participate in 
the study. Subjects were told the purpose of the 
project and their right to decline participation at any 
time. Each participant was paid $5 to complete a 
questionnaire concerning demographics and 
measures of perceived support, received support, 
depression, coping strategies, desire for control, 
distress, and somatic complaints. Their medical 
records were examined for number of appointments, 
medications prescribed, documentation of 
victimizations, therapy referrals, and types of 
complaints for the last 2 years. Interviews were 
conducted 1 month later to collect reports of client 
satisfaction with services. Care providers were 
asked to complete a questionnaire concerning 
Hispanic cultural knowledge and patient symptoms 
for the medical visit at the time of the study's 
contact with the respondent. 



>* Location - Agencies 

• Mental health 

• Rural 

• Community health 



6% 
10% 
84% 



Major Findings 

Role Of Depression 

FINDING 1: Depression is not a mediator between 
distress and somatic complaints for the low- 
acculturated Latina but is a mediator for the high- 
acculturated Latina. (See Figures 1 and 2.) 

Structural equation modeling was implemented to 
determine if depression mediated between distress 
and somatic complaints for Latinas who are low- 
acculturated and for those who are high- 
acculturated. Results revealed that distress led 
predominantly to somatic complaints and 
moderately to depression for the low-acculturated 
Latina. However, there was no association between 
depression and somatic complaints. For the high- 
acculturated Latina, distress led to depression and 
then to somatic complaints, with a weak direct 
association from distress to somatic complaints. 



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Figure 1 . Low-acculturated Latinas SEM for 
Depression as a Mediator 



Table 1 . Regressions for Location as a Child 



Distress 



B = 0.271 




A = 0.846* 



Somatic Compaints 



Depression 



For this model, X2 = 0.22, df = 1, p = 0.635 (£ < 0.05 for significance); 
Goodness of Fit Index = 0.998. Chi-square was not significant; therefore, 
the model fits as specified. The results show that the path between 
depression and somatic complaints was not needed to improve the fit of the 
model. The model fits as specified with the path between distress and 
somatic complaints (Path B) . Therefore, for the low-acculturated Latina, 
depression is not a mediator between distress and somatic complaints. For 
this group, distress leads to somatization. 



Figure 2. High-acculturated Latinas SEM for 
Depression as a Mediator 



EHstress 



B = 0.448* 




0.403* 



y^ Somatic Complaints 



For this model, X2 = 18.81, df = 1, p = 0.001 (e < 0.05 for significance); 
Goodness of Fit Index = 0.995. Chi-square is significant; therefore, the 
model does not fit as specified. The modification indices reveal that the 
path between depression and somatic complaints (1 8. 13) accoimts for most 
of the lack of fit in the model. Thus, the results showed that the path 
between depression and somatic complaints (Path C) was needed to 
improve the fit of the model. For the high-acculttu-ated Latina, depression 
is a mediator between distress and somatic complaints. 



These findings provide evidence that there are 
intracultural differences concerning the influence of 
depression on the manifestation of somatic 
complaints. Depression is not an indicative factor 
for somatic complaints of low-acculturated Latinas; 
thus, antidepressants may not be needed to treat 
somatization of these patients. The insignificance 
of depression facilitates the cultural coding that 
somatization is a modality to elicit support. 
Therefore, modes of support should be explored to 
reduce distress and somatic complaints. 

FINDING 2: The predictive role of depression 
varies across acculturation levels, the length of 
time in the United States, and the residence of 
childhood. (See Tables 1 and 2.) 



Variable 


n 


R^ 


B 


SEB 


BET 
A 


Raised in 
Hispanic 
Country 


80 


0.08 


- 


- 


- 


Depression 






0.167 


0.294 


0.07 


Distress 






0,704 


0.410 


0*'20 


Raised in 
United States 


320 


0.14 


- 


- 


- 


Depression 






0.526 


0.094 


0.32* 


Distress 






0.169 


0.097 


0.10 



*E<0.05. 

lA&LE 2. Regressions for Length of Time in the 
United States 



Sample 










a 


R^ 


Variable 


BETA 


<5yrs 


45 


0.08 


Depression 
Distress 


0.12 
0.14 


<15yrs 


82 


0.13 


Depression 
Distress 


0.14 
0.27* 


<25yrs 


200 


0.11 


Depression 
Distress 


0.19* 
0.19* 


<30yrs 


237 


0.12 


Depression 
Distress 


0.23* 
0.18* 


<35yrs 


271 


0.12 


Depression 
Distress 


0.28* 
0.13* 



♦e<0.05. 

Regressions were implemented to determine the 
predictive role of depression at varying 
acculturation levels, the length of time in the United 
States, and childhood residence. The results 
revealed that depression was not a predictor of 
somatic complaints for the low-acculturated Latina. 
It gained significance for the bicultural Latina, and 
dominated the forecast of somatic complaints for 
the high-acculturated Latina. In further regressions 
that were conducted on Latinas at increments of 5 
years in the United States, the results exposed the 
insignificance of depression in the prediction of 
somatic complaints until the Latina had lived 25 



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years in the United States. By 35 years in the 
United States, depression became the dominant 
predictor of somatization. Regardless of age, 
depression was not a predictor of somatic 
complaints for Latinas who resided only in a 
Hispanic country for their first 18 years. However, 
depression was the strongest predictor of 
somatization for Latinas raised only in the United 
States. Furthermore, R^, which determines the 
amount of variance explained, never exceeded 30%, 
thus indicating that depression is not as influential 
in the manifestation of somatic complaints for the 
high-acculturated Latina as for the European- 
American woman. 

These findings further support inter- and 
intracultural differences concerning depression and 
somatic complaints. A further interpretation of 
these results acknowledges the use of somatic 
complaints to manage distress; however, the 
antecedent contributing factors of this modality are 
influenced by culture and acculturation. 

Relationship Between Distress and Somatic 
Complaints 

FINDING 3: Distressors predict somatic 
complaints. (See Tables 3 and 4.) 

Table 3. Summary of Regression Analyses for 
Distress Variables That Predict Somatic 
Complaints (N = 465) 



Table 4. Summary of Distressor Freouencies 
AND Somatic Complaint Means (N = 465) 



Variable 


B 


SEE 


BETA 


Sexual Assault 


1.191 


0.442 


0.319* 


Domestic Violence 


0.462 


0.272 


0.175 


Poverty 


0.933 


0.242 


0.293* 


Sexual Assault by 
Domestic Violence 


-0.094 


0.068 


-0.255 


Sexual Assault by 
Poverty 


-0.121 


0.062 


0.253 


Domestic Violence 
by Poverty 


-0.064 


0.038 


-0.221 


Sexual Assault by 
Domestic Violence 
By Poverty 


0.016 


0.008 


0.392* 





Somatic Svmptom 


Variable 


n % Range Means Severity 


No 
Trauma 


56 


13.0 


0-37 


7.80 


1.66 


Sexual 
Assault 


8 


2.0 


0-38 


8.50 


1.75 


Domestic 
Violence 


29 


6.5 


0-34 


8.59 


1.72 


Poverty 


110 


25.0 


0-43 


9.39 


1.55 


Domestic 
Violence 
by Sexual 
Assault 


20 


4.5 


0-35 


10.25 


1.78 


Domestic 
Violence 
by 
Poverty 


90 


21.0 


0-45 


13.97 


1.76 


Sexual 
Assault 
by 
Poverty 


14 


3.0 


0-41 


16.00 


1.79 


All Three 
Traumas 


109 


25.0 


0-45 


18.34 


1.82 



*E<0.05. R^ = 0.11. 



Note: Rangeof somatic complaints, 0-90. Range of symptom 
severity, 1-5. 

Sexual assault, domestic violence, and poverty were 
examined as distressors that invoke somatic 
complaints. Regression analyses revealed that 
sexual assault, poverty, and the combination of the 
three distressors predicted somatization. However, 
none of the two-way combinations of the distressors 
nor domestic violence alone predicted somatization. 
Significant differences in both symptom means and 
symptom severity were found between the no- 
trauma group and the group that experienced all 
three victimizations. 

The differences in groups that experienced no 
trauma (13%) and all three traumas (25%) revealed 
that those with no trauma reported lower symptom 
means (7.80) than those with all three traumas 
(1 8.34). Furthermore, the no-trauma group reported 
symptom severity means of 1.66, whereas the high- 



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trauma group noted a symptom severity means of 
1.82. 

These findings revealed that the distressors 
contributed to the manifestation of somatic 
complaints for the Latina. One possible 
explanation for the high level of distress created 
by these victimizations may be that it is difficult for 
the Latina to access services to assist her with the 
aftermath of sexual abuse or to transcend the effects 
of poverty. Additionally, family support may be 
limited because of belief systems and lack of 
resources. Thus, an indicator for somatization may 
be a history or presence of these events. 

The nonsignificance of domestic violence as a 
predictor of somatic complaints may be due to 
multicolinearity with poverty, which makes it 
difficult to determine its single effect. Also, using 
somatic complaints may be a failed strategy for this 
group because support from intimate others is 
typically not available. 

The mean level of somatic complaints indicated 
that many Latinas somaticize (83%), and that the 
more distress experienced, the more somatization. 
Regardless of the distress level, symptom severity 
remained relatively low. Seemingly, distress 
increases the number but not the severity of 
physical complaints experienced by the Latina (see 
Table 4). 

If the goal of somatic complaints is to elicit support 
for these distressors, alternative methods of 
treatment need to be explored by care providers. 
Antidepressants or any other medication without 
counseling or some other form of support should 
not alter the effects of these distressors. Ostensibly, 
the distressed Latina will continue to access the 
health care facility due to inappropriate treatment 
and the lack of other resources. 

Implications 

There are inter- and intracultural differences for 
Latinas concerning antecedent contributing factors 
to the manifestation of somatic complaints. 
Hispanic/Latina cultural coding facilitates the use 
of this coping strategy as a means to elicit support. 
However, as the Latina became more acculturated, 
she adopted the same presenting characteristics as 
the European-American woman, who displays 



depression in conjunction with somatic complaints. 
Although medication may relieve the symptoms 
related to the discomfort, it did not appear to resolve 
the underlying cause of the complaint. Thus, the 
Latina continues to frequent the facility with low- 
level complaints in search of a cure. 

The problem of overutilized health care facilities is 
a result of a dynamic that occurs between the Latina 
and the system. This dynamic represents 
different cultural codings and coping strategies that 
inhibit the provision of appropriate services. 
Alternative interventions are needed to provide the 
best care for the Latina and to reduce the burdens 
placed upon the public health systems. 

Recommendations 

For change to occur, transformations are needed at 
all levels of the health care system. The reduction 
in overutilization of services by somatic complaint 
patients is a realistic goal that can be achieved. A 
program of change and the enhancement of cultural 
competence can augment the care provided to the 
patient and reduce health care costs. The following 
three areas for remodeling are suggested: 

>* Administrative health care system changes 

• Consistent care providers for patients at health 
care sites 
♦ Commitment to promoting cultural 

competence by activating the following: 

Funding and conducting mandatory 
cultural trainings and seminars for staff 

Hiring and promoting culturally 
competent professional staff 

<> Funding and conducting educational 
and emotional support groups for 
somatic complaint patients 

<> Providing qualified translators at each 
site during all hours of operation 

Identification of the atypical/ 
functional/unspecified somatic com- 
plaint patient (A DSM IV group that is 
not pathological, but is categorized by 
low-level global complaints caused by 
distress) 

<> Reevaluation of client satisfaction data 
collection; development of a 
questionnaire that is culturally 
appropriate for the Latina 



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Training seminars for care providers that focus on 

• Cultural competence 

♦ Depression in the Hispanic culture 

♦ Cross-cultural meaning of illness 

♦ Use of somatic complaints cross-culturally 

♦ Use of key Hispanic health terms 

♦ Effects of institutional racism 

♦ Effects of acculturation and resulting 
differences 

• Identificationof key concepts 

♦ Familial and personal distressors 

♦ Coping strategies 

♦ Influence of education, income, and 
distressors 

♦ Effects of poverty on distress and health 

• Identification and recording of distressors 
(sexual assault and domestic violence) in 
patient's records 

• Identification of the atypical/unspecified/ 
functional somatic complaint patient 

Patient/consumer programs 

• Support groups that 

♦ Are composed of members having similar 
culture, age, and distressors that enhance 
the development of support networks and 
resources to deal with the aftermath of 
victimizations 



♦ Address health concerns such as chronic 
pain management, the fears of certain 
diagnoses, and the fear of death and disease 

♦ Deal with psychosocial needs such as 
loneliness, separation from family, anxiety, 
relationship concerns, and lack of 
community 

♦ Focus on the assets and strengths of the 
Latina 

Educational groups focusing on 

♦ Positive problem solving 

♦ Increasing self-esteem and self-confidence 

♦ Resolving relationship problems 

♦ Stress management 

♦ Acculturation processes and effects 

♦ Personal responsibility for each person's 
well-being 

♦ Accessing public assistance systems in the 
United States 

The development of informal community 
support groups without a professional facilitator, 
which use neighborhood volunteers who offer 
support to somatic complaint patients 
Resource directory of culturally competent 
community services 



REFEREHCE 



Katon E, Kleinman A, Rosen G. Depression and 
somatization: A review (part 1). Am J Medicine . 1982; 
72(127-153). 



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MENTAL ILLNESS: THE NEXT 
GENERATION 

Dawn I. Velligan, Ph.D. 

Clinical Assistant Professor of Psychiatry 

University of Texas l-lealth Science 

Center at San Antonio 

Research Specialist on the Clinical 

Research Unit 

San Antonio State Hospital 

Bonnie C. Hazleton, M.A. 

Research Assistant, University of Texas, 

Health Science Center 

San Antonio 

Stacey L. Giesecke, M.S. 

Research Specialist 

Clinical Research Unit 

San Antonio State Hospital 

ABSTRACT 

Research conducted in the early 1960's consistently 
reported low rates of marriage and reproduction in 
chronically mentally ill women, particularly those 
with schizophrenia. More recent work has found 
that both marriage and reproduction rates have 
increased disproportionately in the chronically 
mentally ill compared with the general population. 
The present study examined the marital status and 
number of children bom to 90 women residing at 
the San Antonio State Hospital during a 2-week 
chart review period. Results are discussed with 
respect to the future of mental health services in the 
South Texas area. Children bom to mothers with 
psychotic disorders are at greater risk of developing 
serious mental illnesses due to both genetic and 
environmental factors. Education for women with 
schizophrenia and their significant others is 
stressed, as well as early intervention programs for 
these children. 

Introduction 

Individuals with mental illnesses, particularly 
schizophrenia, have been found to have lower rates 
of reproduction than the general population 
(Erlenmeyer-Kimling, 1978; Gottesman, et al., 
1971). This is more tme for male patients than for 



female patients. Over the past several decades, 
however, population reproduction rates have 
decreased, and some investigators have found that 
reproduction rates within the mentally ill 
population are becoming similar to those in the 
general population (Erlenmeyer-Kimling, et al., 
1969; Haverkamp, et al., 1982; Odegaard, 1980). 
Erlenmeyer-Kimling and colleagues 1966), for 
example, found an increase in marital rates forjhe 
mentally ill from 1934 to 1956. This increase in 
marital rates was greater than the increase in the 
general population. They found a corresponding 
increase in the average number of children per 
person for the mentally ill. During 1934-56 there 
was a 25% increase in the general population 
compared with an 86% increase in schizophrenic 
patients. This represents an increase of 60 children 
for every 100 patients (i.e., twice as many as the 
general population group). We became interested 
in women at the San Antonio State Hospital after 
one patient in her early fifties was visited by her 
eight children. For the present study, over a 2- 
week period we examined half of all the charts for 
female patients at the State Hospital. The hospital 
serves 16 counties in the South Texas area. The 
purpose of the extensive chart review was to 
determine how many women had been married, 
how many had children, and who cared for these 
children. We were particularly interested in the 
implications of this research for planning fiiture 
mental health care in the South Texas area. 

Subjects 

Our sample consisted of 90 women. Nine were 
African Americans, 48 were Mexican Americans, 
and 30 were non-Hispanic whites. Sixty-eight 
percent were from Bexar County surrounding the 
San Antonio area; the remaining 32% were from 
outlying counties extending from Comal County 
north of San Antonio to the U.S. -Mexico border 
region in the south. Patients ranged in age from 1 8 
to 64 with a mean of 42.96 (S.D.=12.86). Patients 
had an average of 7.06 (S.D.=6.22) hospitalizations 
(with a range of 1-16), and 70% of them were on 
Government aid, including SSI, SSDI, food 
stamps, and AFDC. Women in the sample were 
diagnosed as having psychotic disorders — 52% 
with schizophrenia, 21% with bipolar disorder, 
12% with psychotic depression, and 9% with 



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schizoaffective disorder. 

Results 

Results of an extensive chart review revealed that 
77% of women in our population had been married 
at least once. We compared this to the population 
sample obtained in the 1988 national census. 
According to the Bureau of Census, 80% of all 
women over the age of 1 8 are or have been married 
at some time in their lives. Although the 77% is 
lower than the general population percentage, the 
number is quite high considering the severity of 
mental illness in the sample. 

A large percentage of women in our sample had at 
least one child. Seventy-two percent of the 
African- American women had children, as did 82% 
of non-Hispanic white women and 76% of 
Mexican- American women. We also examined the 
number of children per woman in each group. In 
the general population, there are 1.8 children per 
woman (Seager and Olsen, 1986). In our total 
sample there were 2.1 children per woman. In the 
various ethnic groups, we found 2.3 children per 
woman in the Mexican- American women, 1.6 in 
non-Hispanic white women, and 2.1 in African- 
American women. Although slightly fewer 
Mexican-American patients had children than 
non-Hispanic whites, those who did have children 
tended to have more of them. We were unable to 
find statistics regarding number of children per 
woman specific to the area of South Texas served 
by our hospital. Some groups of women in South 
Texas may have more than the 1.8 children per 
woman observed in the general population. The 
rate of 2.3 children per Mexican- American female 
patient may be lower than their population 
counterparts, but this number remains exfremely 
high given the severity of mental illness in the 
women in our sample. Fully 50% of all the female 
patients in our group had at least two children. 

Due to the high number of hospitalizations and the 
chronic nature of illness in our patient population, 
we were concerned about who was taking care of 
these women's children. Results of our chart review 
indicated that 77% of these children were raised by 
someone other than the patient. Relatives of the 
patient, the State, or adoptive/foster families were 
the predominant caretakers for these children. In 



cases where the patient had raised the child, this 
was typically done in conjunction with a husband 
or other supportive family member. Of the 
children who were raised by relatives of the 
patient, only 40% had any contact with the patient 
whatsoever. 

We were also interested in the younger women in 
our sample who were still of childbearing potential. 
There were a total of 30 women between the ages 
of 1 8 and 45 who were not postmenopausal or had 
not been surgically sterilized. Of these 30 women, 
80% were not using any form of birth control. 
Only 6 of the 30 were using barrier methods or 
oral, or depot, medication. When all the women of 
childbearing age were examined as a group, we 
found that 41% of the women were using birth 
confrol or had received tubal ligations. This figure 
compares with 60% of women in the general 
population (Seager and Olsen, 1986). 

What are the Concerns Regarding Women with 
Schizophrenia and Other Major Mental Illnesses 
Having Children? 

Schizophrenia, bipolar disorder, and other major 
mental illnesses have a genetic component (Kaplan 
and Sadock, 1988; Ritsner, Sherina, and Ginath, 
1992). For example, with schizophrenia, chances 
of developing the disorder increase with degree of 
relatedness to the affected member and the number 
of affected members in the family. In the general 
population, the risk for developing schizophrenia 
is 1%. The risk for a child with one parent with 
schizophrenia is about 12%), and the risk for a child 
of two schizophrenic parents is approximately 40% 
(Kaplan and Sadock, 1988). Due to factors such as 
assortative mating, many of the women in our 
sample had children with men who were also 
mentally ill. Furthermore, although the children of 
schizophrenic parents may not develop 
schizophrenia, they may still have significant 
deficits in attention and information processing and 
show poor school performance, possibly due to 
shared genetic inheritance (e.g., Marcus, et al., 
1993). Many studies have documented such 
deficits in the unaffected relatives of patients with 
schizophrenia (Mahurihn, Velligan, and Miller, 
1993; Nuechterlein and Dawson, 1984; Wagener, 
et al., 1986). Thus, the genetic risk for developing 
schizophrenia and/or various cognitive deficits in 



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these children is very real. 

Environmental factors may also increase the risk to 
these children. Schizophrenic mothers in general 
have poorer prenatal care and more birth 
complications, both of which increase the 
likelihood of the child developing mental illness at 
a later age (Goodman and Emory, 1992). 
Furthermore, the home lives of some of these 
children being cared for by the State, foster 
parents, or assorted relatives (who may have 
subclinical signs of schizophrenia or spectrum 
disorders themselves) may be very chaotic. 

What are the Barriers to Contraceptive Use in 
This Population? 

A study by McEvoy, et al. (1993) reviewed 
potential barriers to the use of contraception in this 
population. Some of the reasons cited in this article 
and seen in the clinical care of our patients at the 
State Hospital included the following: 1) cognitive 
deficits, 2) delusional beliefs, 3) desire to raise a 
family, 4) misconceptions regarding birth control, 

5) misconceptions regarding schizophrenia, 

6) shortened hospital stays, and 7) patients' rights 
issues. Patients with schizophrenia, for example, 
have been known to demonstrate impairment in a 
wide range of cognitive functions compared with 
age-matched control subjects (Green, et al., 1992; 
Gold and Harvey, 1993; Nuechterlein and Dawson, 
1984; Waddington, Yousseff, and Kinsella, 1990). 
Judgment and planning ability are often 
significantly impaired (Gold and Harvey, 1993; 
Saykin, et al., 1991). Although many female 
patients state that they do not want to get pregnant, 
they may not be using any birth control due to the 
impairment in their ability to plan and anticipate 
events. In addition, cognitive deficits may cause 
patients to overestimate their ability to flinction 
with and care for a child. 

Delusional beliefs regarding medication and doctors 
may prevent patients from developing trusting 
relationships necessary to discuss birth control. In 
addition, delusions of pregnancy can occur in which 
the patient believes she is already pregnant and 
therefore not in need of birth control. Getting 
married and having children are viewed as part of 
being "normal," and the desire not to be ill is very 
strong. As does almost everyone, these women 
want the love and closeness that comes from family 



life. As in the general population, subgroups of 
female patients believe that taking birth control 
conveys a message that they are "loose." 

Some patients have difficulty understanding or 
accepting the chronic nature of the illness and 
believe that when certain symptoms subside, they 
no longer have the illness. They believe that 
because they are well, there is no need to be 
concerned about their ability to raise a cMld. 
Patients may also underestimate the impact of 
stress on their illness. Patients often need many 
years of experience managing the illness to 
understand the role of stress in symptom 
exacerbation and rehospitalization. After many 
years of coping with schizophrenia, patients may 
be more aware that they would not be able to cope 
with the stress involved in raising a family. 
Shortened stays in the hospital also decrease the 
chance for a strong therapeutic alliance to allow the 
patient to feel comfortable discussing issues of 
reproduction and birth control. In any discussion 
of birth control, the rights of the patient must be 
respected so that the patient is not coerced into 
doing something she does not want to do. 
Cloverdale, et al. (1993) provided a good 
discussion of these issues. Unfortunately, some 
physicians are so careful about patient rights that 
they do not discuss the issue of birth control unless 
it is brought up by the patient. 

Implications AND Plans for the Future 

It will be important for South Texas and the border 
region to work toward providing better education 
for the mentally ill about birth control and about 
their illness while they are hospitalized. As 
hospitalizations are getting shorter, this is 
becoming more difficult. However, if birth 
control could be initiated in the hospital and 
compliance monitored by outpatient services, we 
may find that we will have less business in the 
future. 

Treatment teams in both inpatient and outpatient 
services may need to make primary prevention a 
goal— explaining to women of childbearing 
potential the difficulties of pregnancy and 
childrearing in the context of their mental illness. 
This must be done in such a way as to preserve the 
rights of the patient as described in Cloverdale, et 



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al., 1993. 

Finally, it may be helpful to initiate specialized 
programs for children bom to mentally ill mothers, 
particularly those at highest risk (i.e., those whose 
fathers are also mentally ill, those pregnancies in 
which substance abuse has been an issue, and 
children who had birth complications). Such 
programs could target skills in attention and 
information processing. Initially, these programs 
would be experimental, but research could 
determine whether such programs could prevent or 
delay the onset of psychotic symptomatology in 
vulnerable offspring. 

The results of this chart review are particularly 
important in light of the policy changes being 
discussed in Washington. Legislators say that more 
than 60 million recipients of government aid are 
children. Clearly the mentally ill and their children 
rely to a great extent on government aid. It is 
imperative that they not be forgotten in the 
government's efforts to get everyone back to work. 

DthAOGRAPHic Characteristics 



Total Sample = 90 Women 
9 African-American 48 Mexican- American 30 Non-Hispanic Wlilte 
68 %from Bexar County 32%rrom Outlying Counties 

Age Range 18-64 Mean Age 43 
# of Hospitalizations Range 1-16 Mean = 7.06 
70%on Government Aid (SSI, SSDI, Food Stamps) 



Marriage Rates 

General Population Hospitalized Wome 

20% 




80% 



77% 



1 Married 

2 Never married 



Percentages of Women With Children 




m African-American 
■ Non-Hispanic White 
i) Mexican-American 



Percentages of Women with Children 



Number of Children per Woman 



Diagnostic Characteristics of Psychotic 
Disorders 

>■ 21% Bipolar Disorder 

>■ 12% Psychotic Depression 

> 9 % Schizoaffective Disorder 

> 52% Schizophrenic Disorders 




General Rpulation 
Total Staple 
Nfexican- American 
Nmi Hqjanic White 
African- Anerican 



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Percentage of Children Cared for 
BY THE Patient 



Raised by the Patient 
23% 




Raised by Other 
77% 



Risk for Developing Schizophrenia 

>- General Population 1% 

> Child with one Schizophrenic Parent 1 2% 

>> Child with two Schizophrenic Parents 40% 

Plans for the Future 

>■ Education for women on acute and extended care 

units and in aftercare 
>* Active involvement of the treatment teams in 

primary prevention 
^^ Special programs for children bom to mentallyill 

mothers 



Use of Birth Control 



80% 

Not using any 

(n=24) 




20% 

using some form 

(n=6) 



If you include female patients with tubal 
ligations, 4 1 % are using birth control as 
compared to 60% in the general population. 



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REFERENCES 



Cloverdale JH, Bayer TL, McCuUough LB, Chervenak 
FA. Respecting the autonomy of chronic mentally ill 
women in decisions about contraception. Hosp Comm 
Psvchiatr . 1 993 ;44:7(67 1-674). 

Erlermieyer-Kimling L. Fertility of psychotics: 
Demography. In: Cancro R (Ed.), Annual review of 
the schizophrenic syndrome . New York 
Brunner/Mazel, 1978;298-333. 

Erlenmeyer-Kimling L, Nicol S, Rainier JD, Deming 
WE. Changes in fertility rates of schizophrenic 
patients in New York State. Am J Psychiatry . 
1969;125(916-927). 

Erlenmeyer-Kimling L, Rainier JD, Kallman FJ. 
Current reproductive trends in schizophrenia. In: Hoch 
PH, Zubin J (Eds.), Psychopathology of schizophrenia . 
New York: Grune & Stratton, 1966;252-276. 

Gold JM, Harvey PD. Cognitive deficits in 
schizophrenia. Psvch Clinics N.A. . 1 993; 16:2(295- 
312). 

Goodman SH, Emory EK. Perinatal complications in 
births to low socioeconomic status schizophrenic and 
depressed women. J Abnormal Psychol . 1992; 
101:2(225-229). 

Gottesman I, Erlenmeyer-Kimling L., Differential 
reproduction in individuals with mental and physical 
disorders. Supplement to Social Biology . 1 97 1 ; 1 8:5 
(1-8). 

Green MF, Satz P, Ganzell S, Vaclav JF. Wisconsin 
Card Sorting Test performance in schizophrenia: 
Remediation of a stubborn deficit. Am J 
Psvchiatrv . 1992: 146C: 1(62-66). 

Haverkamp F, Propping P, Hilber T. Is there an 
increase of reproductive rates in schizophrenics? 
Critical review of the literature. Arch Psychiatr 
Nervenkrankh . 1982;2 32(439-450). 

Kaplan HI, Sadock BJ. In: Synopsis of psychiatry 
behavioral sciences clinical psychiatry . 5* Ed., 
Baltimore, MD: Williams & Wilkins, 1988. 



Mahurihn RK, Velligan DI, Miller AL. Negative 
symptom expression and cognitive impairment in 
schizophrenic patients and their biological mothers. 
Schizophr Res . 1993;9(182). 

Marcus J, Hans SL, Auerbach JG, Auerbach AG. 
Children at risk for schizophrenia: The Jerusalem 
Infant Development Study. Arch Gen Psychiatry . 
1993;50(797-809). 

McEvoy JP, Hatcher A, Appelbaum PS, Abemethy V. 
Chronic schizophrenic women's attitudes toward sex, 
pregnancy, birth control, and childrearing. Hosp 
Comm Psvchiatr . 1993;34:6(536-539). 

Nuechterlein KH, Dawson ME. Information processing 
and attentional functioning in the developmental course 
of schizophrenic disorders. Schizophrenia Bulletin . 
1984;10:2(160-203). 

Odegaard O. Fertility of psychiatric first admissions in 
Norway 1936-1975. Acta Psychiatr Scand . 1980; 
62(212-220). 

Ritsner M, Sherina O, Ginath Y. Genetic 
epidemiological study of schizophrenia: Reproduction 
behaviour. Acta Psvchiatr Scand . 1992;85(423-429). 

Saykin AJ, Gur RC, Gur RE, Mozley PD, Mozley LH, 
Resnick SM, Kester B, Stafmiak R. 
Neuropsychological function in schizophrenia: 
Selective impairment in memory and learning. Arch 
Gen Psychiatry . 1991; 48(618-622). 

Seager J, Olsen A. Women in the world, an 
international atlas . New York: Simon & Schuster, Inc., 
1986:23-37. 

Waddington JL, Yousseff JA, Kinsella A. Cognitive 
dysfunction in schizophrenia followed up over five 
years, and its longitudinal relationship to the emergence 
of tardive dyskinesia. Psychological Medicine . 
1990;20(835-842). 

Wagener DK, Hogarty GE, Golstein MJ, Asamow RF, 
Browne A. Information processing and communication 
deviance in schizophrenic patients and their mothers. 
Psychiatry Res . 1 986; 1 8(365-377). 



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VIOLENCE AGAINST WOMEN 

VIOLENCIA CONTRA LA 
MUJER 

Yoliria Joch Gonzalez 

Association of Professional Women of 

Tamaulipas (Ciudad Victoria, Tamaulipas, 

Mexico) 

ABSTRACT 

Purpose 

To understand the etiology of violence against 
women 

Methodology 

Documented research of news articles 

Descriptive research carried out through surveys 
and field observation 

Summary 

Violence against women is not exclusive to any 
social class. In analyzing this violence, we find that 
is an ongoing battle. Review of news articles 
confirms the existence of victims of abuse, which 
includes physical abuse, verbal insults, homicides, 
and other forms of violence. These forms of abuse, 
together with intimidation, lack of economic 
support, psychological abuse, and sexual and 
emotional harassment are commonplace enough 
that they are not reported to the police. Based on 
observation in different regions of the State of 
Tamaulipas, an increase in violence against women 
has been observed since 1993. Etiological analysis 
reveals contributing factors specific to each region. 

Resumen 

En los municipios de la frontera son mas frecuentes 
las agresiones, el maltrato fisico, homicidio y 
hostigamiento sexual. 

En la region central, vejaciones emocionales, falta 
de apoyo familiar, maltrato fisico y hostigamiento 
sexual. 



En las zonas aridas, enfrentan el abandono y falta de 
apoyo economico. 

La federacion de mujeres sindicalizadas indica 
que el 90% de las mujeres trabajadoras sufren 
maltrato en diversas modalidades. 

Conclusiones y comentarios: la violencia contra la 
mujer existe en todas las clases sociales. 

La agresion se encuentra dentro y fuera del contexto 
familiar. 

El hostigamiento sexual de la mujer trabajadora 
existe en todas las regiones. 

En el hogar, la agresion existe en un 95% por 
parte de supareja. 

Lo mas significativo es que cuando la mujer es 
insultada o golpeada, se encuentran presentes sus 
hijos, con la consecuencia logica de trastomos 
emocionales, disfuncion familiar y falta de valores 
que fortalezcan la unidad familiar. 

Tema: "Violencia Contra la Mujer" 

"No hay nada mas poderoso que una idea a la que le 
llego su tiempo". 

El proposito de la investigacion sobre el tema que 
nos ocupa es el de conocer la etiologia de la 
violencia contra la mujer en todos los renglones de 
deterioro, teniendo entre ellos el fisicoemocional, 
educative, social, economico y cultural. 

Nuestras mujeres han estado expuestasa a la 
violencia desde pequeiias, debido a que la educacion 
familiar establece diferencias de genero y la etiqueta 
de servidora del hogar, con capacidad reproductora 
y con tutela parental bajo normas rigidas por el solo 
hecho de ser mujer. 

La consecuencia es la aspiracion legitima de que se 
le otorgue el mismo valor que al varon, comenzando 
la etema competencia con un sin numero de 
obstaculos para la mujer. 

La ancestral sumision de la mujer, culturalmente 
hablando, ha dado pauta para que se transmita la 
forma de educar. Cuando la mujer decide ser 
tratada como persona, tiende a ser sometida en 
diversas formas, por haber tenido la osadia de 
pensar por si misma. 



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Asi tenemos el abandono de su pareja por tiempo 
indefmido, sin preocuparse de la familia que deja y 
que puede volver como si no hubiera pasado el 
tiempo y no existiera la responsabilidad patema; en 
contraposicion, la mujer debe guardar absoluta 
fidelidad y velar por su familia hasta el regreso de 
su pareja, y recibirlo porque es el "padre de sus 
hijos". 

Sin embargo, la violencia contra la mujer no es 
privativa de la clase economica baja, sino que se 
presenta en todas las clases sociales y en las formas 
mas diversas, tanto en el hogar como en el trabajo 
y el entomo social. 

Agresion en el Hogar 

Analizando la conducta de la mujer que llega a 
consulta psicologica o un caso de emergencia por 
lesiones fisicas que tardan mas de 15 dias en sanar, 
se observa en primer lugar, el temor hacia la 
pareja, aunado al temor e inseguridad de no poder 
subsistir con sus hijos por falta de recursos 
economicos. Estas prefieren retirar la denuncia y 
soportar la agresion de su pareja y en multiples 
ocasiones prefieren ignorar el abuso sexual de su 
pareja hacia los hijos por los mismos temores y baja 
autoestima. Se ve y se siente devaluada como 
persona, ademas del rechazo hacia sus hijos, cuando 
trata de decirles que pasa. 

Consecuencias: Inseguridad y falta de afecto hacia 
los hijos con riesgo inminente hacia las actividades 
antisociales. 

Agresion en el Renglon Laboral 

De acuerdo a estudios recientes, la creciente 
incorporacion de la mujer a la actividad economica 
no se debe solo al proceso de modemizacion, sino 
que ban tenido que sumarse a estrategias generales 
de ingreso para contribuir a mantener el nivel de 
vida de sus familias, teniendo doble 
responsabilidad, aparte de las tareas domesticas y 
cuidado de los hijos, agregando la responsabilidad 
del trabajo extradomestico. 

Sin embargo, la incorporacion de las mujeres a la 
actividad economica no es condicion suficiente para 
asegurar cambios que le permita alcanzar un mayor 
grado de autonomia personal y participacion en la 
toma de decisiones. Esto se debe a que el nivel 



economico en que las mujeres participan suele ser 
desventajoso para la trabajadora, tanto en jomada 
laboral, disponibilidad de una infraestructura de 
servicios institucionales y del hogar. 

Un dato significativo es que la mas extensa 
participacion economica de las mujeres se asocia 
primordialmente al trabajo por cuenta propia y al 
trabajo familiar, no remunerado. 

Actualmente las mujeres representan mas de la 
mitad de los ocupados en el sector informal de la 
economia. 

En cuanto a las actividades profesionales y tecnicas 
especializadas, se estan "Feminizando" algunas 
ocupaciones y ramas de actividad, pero ello 
tampoco mejoran las condiciones laborales de la 
mujer que se distinguen por: discriminacion salarial, 
segregacion ocupacional, hostigamiento sexual, 
desigualdad de oportunidad de ocupacion, ascenso 
y capacitacion, ademas de incumplimiento de la ley 
laboral y despidos por embarazo. 

De esto podemos recomendar que una de las 
principales lineas de accion para intentar revertir 
dichas condiciones sera el asegurar el acceso 
equitativo de las mujeres al trabajo productivo, el 
empleo, la capacitacion y el adiestramiento, asi 
como a los cursos tecnologicos y financieros en 
igualdad de circunstancias con el varon. 

Ademas de divulgar orientaciones para que las 
mujeres trabajadoras puedan defender sus derechos, 
particularmente aquellas que pertenecen a grupos 
ocupacionales vulnerables. 

En sintesis, habra que poner en practica medidas 
especificas para contrarrestar el escaso valor que se 
asigna al trabajo femenino y a combatir las ideas y 
practicas que cinen al lado femenil, solo a tareas de 
reproduccion y de "casi empleos." 

Definiendo la violencia contra la mujer, 
determinamos que es todo acto, omision, conducta 
dominante o amenaza que tenga o pueda tener como 
resultado: dano fisico, sexual y/o psicologico de la 
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Haciendo un analisis de la violencia contra la mujer 
nos encontramos que estas situaciones representan 
una guerra perpetua. 

Basta repasar las notas periodisticas para 
percatamos de que son victimas de maltrato que va 
desde golpes, vejaciones, violaciones, homicidios y 
otras formas de violencias que se utilizan 
cotidianamente y que por ser tan comunes no son 
motivos de denuncias, teniendo entre ellas: la 
intimidacion, la privacion de apoyo economico, el 
abuso psicologico y muchas otras mas. 

El maltrato no es privativo de ninguna clase social, 
si bien adopta ciertas caracteristicas segiin los 
estratos sociales; en el caso de las mujeres de bajos 
recursos economicos, el panorama es mas sombrio, 
ya que ademas de recibir golpes y abusos 
emocionales, se encuentran en la disyuntiva de 
trabajar en labores domesticas mal pagadas para 
contribuir al sostenimiento del hogar sin tener 
ninguna proteccion juridica, laboral o medica que le 
permita vivir dignamente. 

La mayoria de las mujeres de clase media trabajan 
fuera del hogar en empleos o subempleos, siempre 
y cuando scan jovenes y solteras, encontrandose 
que al tener familia son despedidas de los trabajos, 
sin posibilidades de mejorar y como aportan todo su 
ingreso al hogar, se ven imposibilitadas para 
superarse. 

Las mujeres que han alcanzado cierta posicion 
dentro de la sociedad casi nunca llegan a posiciones 
de poder o a la toma de decisiones en el orden 
economico, sociocultural y politico, porque todavia 
hay patrones ancestrales que impiden 
emocionalmente esta apertura y aquellas que se han 
preparado para ocupar un lugar en la sociedad, se 
les denomina "Atrevidas" y pagan cara su osadia 
siendo victimas de zancadillas y juegos sucios, no 
solo de los varones, sino tambien de nuestro genero. 

La agresion a la mujer se encuentra dentro y fuera 
del contexto familiar: maridos, empleadores, 
padres, hermanos, y muchas mujeres ejercen 
continuamente violencia y presiones tanto fisicas 
como emocionales y sociales para mantener en una 
posicion vulnerable al maltrato, marital o laboral, 
haciendo mas dificil la situacion. 



La mujer ante el temor de perder el empleo que le 
permite dar de comer a sus hijos y conservar a la 
familia unida, se convierte en complice silenciosa 
de su victimario. 

Con respecto al hostigamiento sexual, generalmente 
no lo denuncian por miedo a perder el empleo, o por 
la falta de apoyo familiar y social, lo que 
desencadena un sentimiento de enojo, miedo, 
desamparo y perturbacion psicologica. 

Si establecemos regiones, nos encontramos que en 
los municipios de la frontera son mas frecuentes las 
agresiones y el maltrato fisico y aumenta el delito 
de homicidio contra la mujer. 

En la region centro la agresion ejercida contra la 
mujer es la critica constante con vejaciones 
emocionales sobre la crianza de hijos, por las 
labores del hogar, el nulo apoyo familiar y 
sobreviene el maltrato fisico cuando se atreve a 
protestar, aunque ella sea la mas productiva en el 
hogar. 

Las mujeres en las regiones aridas se enfrentan al 
abandono y a la falta de apoyo economico por la 
emigracion de la pareja, el cual ni regresa, ni envia 
dinero para el sostenimiento de la familia. 

Se debe agregar que los crimenes que se cometen 
contra indefensas mujeres, en la mayoria de los 
casos quedan impunes ante la indiferencia de la 
sociedad. 

En el 95% de los casos, el agresor es su pareja, 
utilizando esta agresion como una forma de 
liberarse de las presiones familiares y extra- 
familiares, existiendo tambien violencia entre 
padres e hijos y entre hermanos. 

Por otra parte la Federacion Mexicana de Mujeres 
Sindicalizadas indica que el 90% de las mujeres 
sufren de maltrato en sus diversas modalidades. 

El indice reportado por las diferentes instituciones 
que prestan sus servicios a victimas que han sido 
agredidas en su persona es poco relevante debido a 
que esta considera que es algo vergonzoso y deciden 
ocultar los hechos y guardar silencio. 

Lo mas significativo es que cuando las mujeres son 
golpeadas o insultadas, estan presentes los hijos, 



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provocando dentro de todo deterioro familiar, 
trastomos psicologicos y patrones negatives que 
desafortunadamente son repetitivos. 

LOGROS 

En 1953, la mujer tiene derecho de voto y se le 
considera ciudadana, asi como en 1974, adquiere la 
igualdad legal en nuestra Carta Magna. 

En la politica falta mucho por hacer, la 
participacion de la mujer todavia es pobre, sobre 
todo a nivel de decisiones, pues tiene que hacer 
doble trabajo y esfuerzo para llegar a un puesto 
publico y/o a un cargo en la politica. 

Para lograr incrementar la atencion a victimas de 
delitos de violencia fisica, psiquica y sexual y 
garantizar los derechos humanos, asi como lograr la 
rehabilitacion psicologica individual, familiar y 
social que la ofendida necesita, por lo tanto, 
sugerimos lo siguiente: 

Propuesta 

>■ Es necesario una revision a nuestras leyes 

juridicas recomendando que en lo que respecta a 
los delitos sexuales, se realice examen medico 
para valorar si existe en el agresor el sindrome de 
inmunodeficiencia adquirida (SIDA), y asi mismo 
que las victimas reciban tratamiento 
psicoterapeutico ya sea psiquiatrico y/o 



psicologico, como recuperacion del dano causado 
en su persona, recomendando que esta sea 
revisada por personal femenino especializado en 
la materia del delito. 

>' La creacion de fiscalias especializadas en delitos 
sexuales, prestando la atencion que requieran las 
victimas que por alguna razon se encuentran 
involucradas en alguna averiguacion previa penal 
o proceso, en el que pudieran verse afectadas en 
su integridad fisica o moral. 

>► Consideramos necesario y urgente el 

funcionamiento de un centro de atencion a 
victimas de abuso sexual y maltrato, con la 
finalidad de brindar una atencion psicoterapeutica 
especializada y a su vez integral, apoyado por un 
equipo de medicos-tecnicos interdisciplinario. 

3*^ Para complementar y apoyar lo anterior se hace 
necesario formar para el beneficio de las mujeres 
agredidas y su familia, casas hogares temporales, 
y bolsas de trabajo, con la finalidad de dar una 
ayuda y proteccion a la comunidad. 

^^ Educar a la mujer con valores y principios que 
fortalezcan su autoestima y su capacidad de 
decision ante su pareja y sus hijos. 

POR Ultimo, Dejo a Ustedes una Reflexion 

"La causa de la mujer, es la causa de la humanidad, 
pues la mujer siempre ha sido el eje del mundo y es 
faro y guia de todas las generaciones." 



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LEGAL OPTIONS FOR VICTIMS 
OF DOMESTIC VIOLENCE 

Jeana Lungwitz, J.D. 

Women's Advocacy Project, Inc. 

Austin, Texas 

ABSTRACT 

The purpose of this paper is to provide concise 
information about legal options for victims of 
domestic violence in Texas and how to access the 
legal system. This paper begins with a brief history 
of the evolution of domestic violence laws. The 
following topics are covered: filing criminal 
complaints (assault, sexual assault, terroristic 
threats, and stalking); restraining orders (how they 
are different from protective orders); protective 
orders (what they are and how to get one); personal 
injury lawsuits; Violence Against Women Act (civil 
rights remedies, interstate enforcement of protective 
orders, and self-petitioning for immigrant victims); 
and how to access free legal services. 

Introduction 

History of Domestic Violence Laws 

>* Roman law — A man had the right to determine 
life or death over all persons in his family. 

> 1 824 — Mississippi Court — "Moderate 
chastisement would be allowed to enforce the 
salutary restraint of domestic discipline." 

>► 1864 — North Carolina Court (State v. Black) — 
Held that even though the husband had choked his 
wife, "the law permits him to use toward his wife 
such a degree of force as necessary to control an 
unruly temper and make her behave herself" 

> 1871 — Alabama Court (Fulgham V. State) — 
Held that men no longer had the right to beat their 
wives. 

> 1 879 — Texas Court (Owen v. State) — Made 
spouse abuse a crime in Texas. 

>* Since then, the law has evolved to where it is 
today— laws that look good on paper but require 
enforcement and education of the public, 
attorneys, judges, and law enforcement persoimel 
in order to work. 



Criminal Complaint 

5* Assault (Texas Penal Code, Section 22.01) 

• Intentionally, knowingly, or recklessly 
causing bodily injury to another, 
INCLUDING ONE'S SPOUSE (emphasis 
added) (e.g., it hurts or leaves marks, bruises) 

♦ Class A misdemeanor - fme up to $4,000 
and/or jail up to 1 year 

• Intentionally or knowingly threatens^nother 
with imminent bodily injury, INCLUDING 
ONE'S SPOUSE (emphasis added) (e.g., "you 
leave with the kids and I'll kill you.") 

♦ Class C misdemeanor - fine up to $500 

• Intentionally or knowingly causes physical 
contact with another when the person knows 
or should reasonably believe that the other 
will regard the contact as offensive or 
provocative (emphasis added) (e.g., 
restraining her from leaving, an unwanted 
kiss) 

♦ Class C misdemeanor - fine up to $500 
>* Sexual Assault (Texas Penal Code, Section 

22.01 1) (Only the sections pertaining to sexual 
assault of adults are shown.) 
A person commits an offense if the person 
intentionally or knowingly 

• Causes the penetration of the anus or female 
sexual organ of another person by any means, 
without that person's consent 

• Causes the penetration of the mouth of another 
person by the sexual organ of the actor, 
without that person's consent, or 

• Causes the sexual organ of another person, 
without that person's consent, to contact or 
penetrate the mouth, anus, or sexual organ of 
another person, including the actor. 

This is a felony of the 2nd Degree - punishable by 

between 2 and 20 years in prison or a fine of up to 

$10,000 or both. 
Note: This was amended in 1993 so that spouses no 
longer have to show bodily injury or threat of bodily 
injury in order to prove sexual assault. 
>- Terroristic Threat (Texas Penal Code, Section 

22.07) (Only the relevant text is included.) 

• A person commits an offense if he threatens to 
commit any offense involving violence to any 
person or property with intent to place any 
person in fear of imminent bodily injury or 
death. 



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• This is a class B misdemeanor — punishable 
by a fine of up to $2,000, confinement in jail 
for up to 1 80 days, or both. 

>- Stalking (Texas Penal Code, Section 42.07 1 ) 

• The following three things must happen before 
someone can be arrested for stalking: 

♦ The stalker must behave in a harassing, 
annoying, alarming, abusing, tormenting, 
or embarrassing way (e.g., repeatedly 
calling, sitting across the street from 
where the victim lives or works). 

♦ The stalker must threaten, by acts or 
words, to inflict bodily injury on that 
person, or to commit an offense against 
that person, or to commit an offense 
against a member of that person's family, 
or to commit an offense against that 
person's property. 

♦ The person toward whom the conduct is 
directed must report this conduct to a law 
enforcement agency. 

This is a Class A misdemeanor (pimishable by a 
fine of up to $4,000, confinement in jail for up to 
a year, or both), unless convicted two or more 
times, then it is bumped up to a 3rd degree felony 
(punishable by confinement for 2 to 10 years in 
prison or in jail for up to a year, a fine of up to 
$10,000, or both). 

• The following things should be noted about 
this legislation: 

♦ The threat does not have to threaten 
bodily injury to the victim. It can threaten 
to commit an offense against the victim's 
property or family (e.g., "I'm going to kill 
your dog," "You'll never see your child 
again." [in a case where a custody order 
has been issued]); 

♦ A high percentage of those violating the 
stalking law will also be violating Section 
22.07(a)(2) (Terroristic Threats). Law 
enforcement should note that in most 
cases when the first report is made, they 
may go ahead and press charges under 
Section 22.07(a)(2) of the Texas Penal 
Code. 

♦ Many people who do not have the 
required relationships to get a protective 
order may be protected by the stalking 
law. 

♦ Many people who are eligible for 
protective orders may also file a criminal 
complaint for stalking. 



• What happens after the stalker is arrested? 
Three other laws were passed to complement the 
effectiveness of the stalking law. These laws 
pertain to what can happen after a stalker is 
arrested. They are as follows: 

♦ Articles 1 7.46 and 42. 1 8 of the Code of 
Criminal Procedure were added. These 
articles provide that a magistrate or the 
parole panel may require that someone 
who is arrested for stalking or convicted 
of stalking may not: 

communicate directly or indirectly 

with the victim 
go to or near the residence, place of 
employment, or business of the 
victim or to or near a school or day- 
care facility where a dependent child 
of the victim is in attendance. 
Note: The language used in the stalking codes is 
similar to the language used in the protective order 
statute. 

♦ Article 56.11 of the Code of Criminal 
Procedure was added to provide that the 
Texas Department of Criminal Justice 
must notify the stalking victim and the 
law enforcement officials in the county 
where the victim resides whenever a 
person convicted of a felony stalking 
crime is released or escapes from prison. 

Protective Order 

> What is a Protective Order (PO)? 

• It is a civil court order that, if violated, can 
have both civil and criminal consequences. 

• The purpose of the PO is to prevent further 
family violence. 

• The PO statute was first enacted in 1979. 
Since then, it has gone through many changes, 
the biggest changes occurring in the 1983, 
1985, and 1995 legislative sessions. 

• The PO statute can be found in Chapter 7 1 of 
the Texas Family Code (TFC) and in section 
3.581 (for a PO in connection with a divorce). 

Note: You can find additional laws pertaining to a 
protective order in connection with a suitfi)r divorce or 
annulment in Section 3.522 of the TFC. 

> What can a Protective Order do? 

• Prohibit fiirther acts of family violence [TFC, 
Section 71.11(b)(1)]. 

• Prohibit the offender from harassing or 
threatening the victim, either directiy or 
indirectly, by communicating the threat 



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through another person, or in certain cases, 
from any type of communication. [TFC, 
Section 71.1 1(b)(2)]. 

• Prohibit the offender from going within a 
specified distance of the victim's home or job 
[TFC, Section 71.11(b)(3)]. 

Note: TFC, Section 71.11 provides that the court may 
exclude the address and telephone number of a person 
protected by this order so that this information will be 
kept confidential. However, this does not mean that 
this part of the order is unenforceable. 

• Prohibit the offender from going to or near the 
residence or child care facility or school where 
a child protected under the order normally 
resides or attends. [TFC, Section 71.11 (b)(4)] . 

Note: The clerk of the court is responsible for making 
sure the protected locations get copies of the order. 
However, it is still a good idea for those protected by 
the order to make sure this is done in a timely manner 
[TFC, Section 71.17(f)]. 

• The Protective Order can prohibit the offender 
from stalking the victim [TFC, Section 
71.11(b)(5))]. 

Note: The offender can be immediately arrested for 
violating the preceding provisions. Violation of 1-5 is a 
class A misdemeanor. 

• Provide for a parent to have possession of and 
access to children [TFC, Sections 
71.11(a)(1)(A) and 71.11(a)(3)]. 

• Set amounts of child support or spousal 
support [TFC, Section 71.11(a)(4)]. 

• Order the batterer into a batterer's treatment 
program or, if one is not available, order the 
batterer into counseling [TFC, Section 
71.11(a)(5)]. 

Note: The court may order only the Respondent 
batterer into counseling or treatment. 

• Provide for possession of mutually owned 
property, such as the home [TFC, Sections 
7 1.1 1(a)(2) and 7 1.1 1(a)(6)]. 

Note: A Protective Order can remove the batterer from 
the home if 

♦ the home is jointly owned or leased [TFC, 
Section 71.11(a)(2)(A)]; 

♦ the home is owned or leased by the party 
retaining possession [TFC, Section 
71.11(a)(2)(B)]; or 

♦ the home is owned or leased by a party 
denied possession IF the party denied 
possession has an obligation to support 
EITHER the party granted possession or a 



child of the party granted possession 
[TFC, Section 71.1 1(a)(2)(C)]. 
Note: If a "kick out order" is granted, the code 
provides that the court must order the sheriff or police 
chief to provide a law enforcement officer to 
accompany the person obtaining the order to the 
residence to protect the person while taking possession 
and inform the person being excluded of the court's 
order to exclude [TFC, Section 71.18(c)]. 

• Prohibit transferring, encumbering or 
otherwise disposing of property [TFC, Section 
71.11(a)(1)(B)]. 

• Catchall provision — Prohibit the Respondent 
from doing specified acts or require the 
Respondent to do specified acts to prevent 
family violence [TFC, Section 71.1 1 (a)(7)]. 

Note: Violations of 6-11 of this outline are punishable 

by civil contempt. 

>■ Who is eligible to apply for a Protective Order? 

• Those persons who are related to the batterer 
by blood or marriage (e.g., parent, spouse, 
sibling, mother-in-law) (see TFC, Sections 
71.01 and 71.04) 

• People who are currently living together or 
who have ever lived together (see TFC, 
Sections 71.01 and 71.04) 

Note: There is no statutory or case law definition of 
"lived together" for the purpose of a Protective Order. 

• People who have had a child together (see 
TFC, Sections 71.01 and 71.04) 

5^ Who can file for a PO? 

• An adult family member on behalf of himself 
or herself or a child [TFC, Section 71.04(b)] 

• Any adult for a child [TFC, Section 7 1 .04(b)] 

• Prosecuting attomey [TFC, Section 71.04(b)] 

• The Department of Protective and Regulatory 
Services (DPRS) can apply for a Protective 
Order on behalf of a victim of family violence 
[TFC Section 71.04(b)(4)]. Although this 
section was probably added to protect 
children, elderly, and the disabled, this section 
does not limit DPRS from filing on behalf of 
anyone else. 

>- Where is the venue for a PO? 

• Where the Applicant resides (TFC, Section 
71.03) 

• Where the batterer resides (TFC, Section 
71.03) 

Note: There is no statutory or case law definition of 
"resides "for the purposes of a Protective Order. Thus, 
a person who has recently moved to (or fled) the State 



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or the county who has the intent of residing in the 
county can get a PO when he or she had not yet met the 
residency requirements for a divorce. 
>- What are filing fees and court costs? 

An Applicant for a Protective Order may not be 
assessed any fee, cost, charge, or expense by a 
clerk of the court or another public official in 
connection with the filing, serving, or entering of 
the Protective Order (TFC, Section 71.041). In 
addition, this section requires the respondent pay 
these costs as well as other costs such as 
reasonable attorneys' fees. 
> Where do you file an application for a Protective 
Order? 

District court, court of domestic relations, juvenile 
court having the jurisdiction of a district court, or 
statutory county court (TFC, Section 71.01). 
Note: TFC, Section 71.09(a) provides that upon filing 
an application for a PO, the court shall set a date for a 
hearing no later than 14 days after filing an application 
(unless you are a prosecuting attorney in a town with 
more than 1.5 million, then it is 20 days [TFC, Section 
71.09(d)]). 
>- What notice is required? 

• The Respondent must receive notice at least 48 
hours prior to the hearing (TFC, Section 
71.09). 

• A person receiving service withia 48 hoxxrs of 
the hearing may request that the court 
reschedule the hearing, but the hearing must 
be held within 14 days of this request (TFC, 
Section 71.09). 

• A PO may be ordered if either the Respondent 
was served more than 48 hours prior to the 
hearing and does not show for the hearing OR 
the Respondent was served less than 48 hours 
prior to the hearing and does not request that 
the court reschedule the hearing (TFC, Section 
71.09). 

^^ What do you have to prove? 

• That family violence has occurred [TFC, 
Section 7 1 . 1 0(a)] . Family violence is defined 
in TFC, Section 71.01(b)(2)(A). Basically it 
amounts to physical pain— visible injuries are 
not necessary— or the threat of physical pain. 
(Sexual assault is specifically defined as 
family violence. In addition, defensive 
measures to protect oneself are specifically 
excluded fi:om the definition of family 
violence.) 

• That family violence is likely to occur again in 
the future [TFC, Section 71.10(a)]. (You do 



not have to prove immediate or imminent 

danger.) 
Note: This element is generally proven by filing soon 
after the incident occurred and/or by showing a pattern 
of repeated violence. 
>■ How long can a PO be in effect? 

• Temporary PO — A court can enter a 
Temporary PO, ex parte, if it determines from 
the application that there is a "clear and 
present danger" of family violence. The court 
can enter the Temporary PO without any 
hearing at all —just based on the application. 
Usually a court will do this if there is no 
request that the batterer be excluded from the 
household. The Temporary PO is good for up 
to 20 days. This 20-day period can be 
extended for additional 20-day periods at the 
request of the Applicant or on the court's own 
initiative (TFC, Section 71.15). 

Note: If the application requests exclusion of the 
Respondent from the household, TFC, Section 71.15(j) 
provides that the judge may stop the hearing to contact 
the Respondent by phone and provide him (or her) an 
opportunity to be present when court resumes. But the 
court MUST resume the hearing befoit^ the end of the 
working day. In addition, for ex parte exclusion of the 
Respondent from the household, the Applicant must 
have resided on the premises within 30 days of the date 
that the application is filed AND the person to be 
excluded must have committed family violence within 
30 days from the date the application is filed [TFC, 
Section 71.15(h)]. 
>- The "permanent" PO is effective for 1 year unless 

the order states a shorter length of time [TFC, 

Section 71.13(a)]. 
Note: Unlike the Temporary PO, there is no 
"extension " of a PO. Once a PO has expired, there are 
two ways to get another PO — 1) if the court finds that 
a person violated a former PO while the former order 
was in effect by committing one of the criminally 
enforceable provisions and the former order is no 
longer in effect, the court SHALL issue a PO that is in 
the Applicant's best interest WITHOUT finding that 
family violence has occurred and is likely to occur in 
the future [TFC, Section 71.10(c)]; 2) if Applicant can 
prove that family violence has occurred since the order 
expired and is likely to occur in the near future. 
>- What are agreed orders? 

• TFC, Section 71.12 provides that in order to 
facilitate the settlement of PO proceedings, the 
Applicant and the Respondent may agree in 



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writing to refrain from the civilly enforceable 
portions of the PO. 

• TFC, Section 71.12 also provides that the 
Respondent may agree to the criminally 
enforceable portions of the PO. 

• In order for a Respondent to get a full PO 
against the Applicant, the Respondent must 
file his (or her) own application (TFC, Section 
71.121). The Applicant must be served with 
Respondent's petition at least 48 hours prior to 
the hearing, and the Respondent must prove 
that the Applicant committed family violence, 
and is likely to commit it in the future [TFC, 
Section 71.10(a)]. 

• The court may not enter a Protective Order 
that requires both the Respondent and the 
Applicant to do or refrain from doing the 
criminally enforceable provisions [TFC, 
Section 71.11 (b)] . The reason for this is that 
mutual Protective Orders have been found to 
be unenforceable due to confusion as to who 
should be arrested. 

>* What can be done if a PO is violated? 

• If a Temporary PO is violated, it is enforceable 
by civil contempt. 

• If the criminally enforceable portions of a 
permanent PO are violated, the batterer can be 
immediately arrested (Texas Penal Code, 
Section 25.07). 

• Section 14.03 of the Code of Criminal 
Procedure was amended to provide that if a 
law enforcement officer is present when a 
criminally enforceable portion of a PO is 
violated, the officer MUST arrest. Other parts 
of that section provide that an officer has the 
authority to arrest anyone that the officer has 
probable cause to believe violated a criminally 
enforceable portion of a PO. 

• Texas Penal Code, Section 25.07(g) provides 
that violation of a PO is a class A 
misdemeanor. 

• Texas Penal Code, Section 25.07(d) provides 
that reconciliatory actions or agreements made 
by a person protected by a PO DO NOT affect 
the validity of the order or the duty of the 
police to enforce the order. 

• Texas Penal Code, Section 25.07(e) provides 
that a police officer investigating conduct that 
may constitute an offense under this section 
may not arrest a person protected by that 
order. 



• Texas Penal Code, Section 25.07(f) provides 
that it is not a defense that the address of the 
victim is excluded from the order. 

• TFC, Section 71.18 provides that each police 
department and sheriff shall establish 
procedures to provide adequate information or 
access to information for law enforcement 
officers of the names of persons protected by 
POs. This section encourages these orders to 
be entered in the computer record of 
outstanding warrants. However, I always 
encourage those with POs to keep their copy 
of their order on their person at all times. 

• Other portions of the permanent PO are 
enforceable through civil contempt. 

>> Can a Protective Order be modified? 

Yes. TFC, Section 71.14 provides that a PO can 
be modified. Either party can make a motion to 
modify to exclude any order included in the 
original order or to include anything not included 
in the prior order that is allowed by statute. 
However, no modification can be made to extend 
the order past its 1 year effectiveness. 

> How does a PO interact with a divorce? 

• A court may not dismiss an application for a 
Protective Order on the grounds that there is a 
divorce pending unless the divorce court has 
already entered or denied a Protective Order 
[TFC, Section 71 .06(b)]. In other words a 
person who has a divorce pending may still 
file for a Protective Order, even if the 
Protective Order is not filed with the divorce 
court. 

• A divorce Protective Order can look just like a 
nondivorce Protective Order. 

♦ The divorce PO can order anything that a 
nondivorce PO can order, even the civilly 
enforceable items such as child support 
and possession of property. 

♦ The divorce PO is still good for up to 
1 year even if the divorce is dismissed. 

♦ The PO is good for a year unless 
otherwise specified on the PO, regardless 
of whether the PO is a divorce or 
nondivorce PO. 

• A divorce PO must be on a separate document. 
It should not be made part of the TRO [TFC, 
Section 71.06(f)]). 

• The PO is in effect until another court with 
proper jurisdiction supersedes it. For example, 
John and Mary divorce. Mar>' gets custody of 
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rights with Little John. After the divorce is 
final, Mary gets a PO against John. That PO 
says that John will now have supervised visits 
of Little John. Until the PO expires or another 
court changes that PO, John will have 
supervised visits. 

Magistrate's Emergency Protective Order 
(Code of Criminal Procedure, Article 1 7.292) 
Many thanks to the Texas Council on Family 
Violence, which provided me with much of the 
information about this law 

> What is a Magistrate's Emergency PO? 

It is a 31 -day PO that can be ordered after a 
batterer/stalker is arrested ft)r family violence and 
is taken in front of a Magistrate. 
>- What can a Magistrate's Emergency PO do? 

• Prohibit fiirther acts of family violence and 
stalking behavior. 

• Prohibit the batterer/stalker from 
communicating directly or indirectly with a 
member of the family or household in a 
threatening or harassing maimer. 

• Prohibit the batterer/stalker from going within 
a specified distance of the residence, place of 
employment, or business of a member of the 
family or household. 

• Prohibit the batterer/stalker from going within 
a specified distance of the residence, child care 
facility, or school where a child protected 
under the order resides or attends. 

>► Who is eligible to apply? 

• The victim of anyone arrested for family 
violence or for stalking. 

>- Who can file for a Magistrate's Emergency PO? 

• Victim 

• Magistrate 

• Victim's guardian 

• Peace officer 

• State's attorney 

> How do you file? 

• The only time this order can be requested is at 
the initial appearance a batterer makes before a 
Magistrate after being arrested. Therefore, it 
is very important to set up a plan for how this 
is going to work. Victims will not know about 
this provision unless we tell them. 

^^ What are the costs? 

• There are none. 

>* What do you have to prove? 

• Essentially, nothing. In order to arrest, the 
police must have had probable cause. The 



arrest in itself should be enough to get this 
protection. 
>» How long is it effective? 

• Thirty-one days; it cannot be extended xmless 
another arrest occurs. 

^^ What can be done if the Magistrate's Emergency 
PO is violated? 

• Call the police. Because the batterer/stalker is 
actually at the hearing before the Magistrate, 
the due process requirement is met. An arrest 
can be made. 

• The first offense is a Class A misdemeanor — 
punishable by incarceration for up to 1 year 
and/or a $4,000 fme. 

• The second offense is a State jail felony, 
pimishable by 1 80 days to 2 years in a State 
jail facility and/or a $10,000 fine. 

• Just like with a PO, a person protected by the 
order cannot be arrested for "violating" it. 

> What happens if a custody conflicts with the 
Magistrate's Emergency PO? 

• The Magistrate's Emergency Protective Order 
will supersede any custody order for the 3 1 
days it is in effect. For example, if the victim's 
children are named as victims, in the 
Magistrate's Emergency PO, the 
batterer/stalker cannot go near the children or 
their protected residence for the duration of 
the 3 1 days, regardless of any preexisting 
custody orders. However, at the end of 31 
days, the previous custody orders remain in 
effect unless the victim has procured a fiiU 
Protective Order that prohibits the 
batterer/stalker's access to the children. 

>* Why do we have this new law? 

• This new law is an attempt to protect victims 
when batterers/staUcers are released from jail. 
Jail release often happens within hours of the 
arrest, putting victims in danger. Also, it 
allows victims of stalking to get a 31-day 
Protective Order. The emergency order is 
NOT a replacement for the PO. It is more 
effective than the Temporary Ex Parte 
Protective Order because the batterer cannot 
be arrested for violating the temporary order. 

Personal Injury Lawsuit/Domestic Torts 

>* Background — Dating back to early English 

common law, neither husband nor wife could sue 
one another for damages for personal injury 
because it would destroy marital harmony and 
cause discord and conflict within the marriage. 



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5=* The first case abolishing the doctrine of 

interspousal immunity is Bounds v. Caudle, 560 
S.W. 2d 925 (Tex. 1977). This case eliminated 
the immunity as to intentional torts. 

^ In 1987 Price v. Price, 732 S.W. 2d 316 (Tex. 
1987) concluded that the theory of interspousal 
immunity should be abolished as to any cause of 
action, saying that courts should afford redress for 
wrongs committed by one spouse against the other 
spouse. 

>* Successful suits have included torts such as the 
following: 

• Physical beatings 

• Deviate sexual acts 

• Transmission of venereal disease 

• Conversion of a spouse's separate property by 
the other spouse 

• Interference with child custody (children are 
often pawns in abusive marriages) 

• Breach of fiduciary duty 

• Fraud 

>* These suits may be brought whether the parties 
are married or not. Usually, if married, these suits 
are made part of the divorce action. 

Violence Against Women Act fVAWA) 

5*^ Gives victims of domestic violence a civil rights 
cause of action if they can prove: 

• They were a victim of a crime of violence 
(must be a felony-level crime, but a VAWA 
action may be brought even if no charges were 
filed). 

• The act must have been motivated by gender. 

• Requires the interstate enforceability of 
Protective Orders 

>" Allows immigrants who are married to U.S. 
citizens to self-petition for residency if they are 
victims of domestic violence. At the moment, it is 
important to tell those immigrants who are 
thinking of getting a divorce that they may want 
to hold off on this for a while until the regulations 
are put into place. They should call the Family 
Violence Legal Line (1-800-374-4673) for more 
information. 

Accessing the Legal System 

>• Those who are financially able may hire a private 
attorney. 



• To be referred to an attorney, people may call 
the State Bar of Texas Lawyer Referral 
Service at 1-800-252-9690; 512-463-1463 (for 
those out of State). 

>" For those who are not financially able 

• Our tax dollars pay for the prosecution of 
criminal cases; hence, there is no need to hire 
an attorney for the prosecution of criminal 
cases. That is the County Attorney's or 
District Attorney's job. 

• Some Coxmty Attorney and District Attorney 
offices provide free help with Protective 
Orders. To find out, one can call those offices 
and ask to apply for a Protective Order. 

• Although there is talk in Congress about 
cutting legal assistance to the poor, right now 
there are legal aid offices that serve each 
county in Texas. To find out which office 
serves a particular county, call the Family 
Violence Legal Line at 1-800-374-4673, and 
an attorney can give you this information. 

• In addition to legal aid, some counties have 
pro bono programs in which private attorneys 
take cases free of charge. To find out if a 
particular coimty has a pro bono program, call 
the Family Violence Legal Line at 1-800-374- 
4673, and an attomey can give you this 
information. 

• Sometimes, shelters for battered women will 
know of attorneys who have worked with 
residents of the shelter for free or at a 
reduced fee rate. This is particularly helpful 
because it indicates that these attorneys have a 
special sensitivity to and knowledge about 
domestic violence. 

• If none of the above is available, one can call 
various private attorneys and try to persuade 
them to take a case pro bono. It may take a lot 
of phone calls, but sometimes this works. 

• When all else fails, it is important to remember 
that there is no law that says one has to have a 
law license to represent himself or herself. 
Although I do not recommend this option if 
there are ANY other resources available, when 
it is the only option, it may be better than 
nothing. 



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VIOLENCE AND BORDER 

WOMEN: AN EMPOWERMENT 

MODEL OF PREVENTION AND 

INTERVENTION 

Linda K. Woodruff, D.S.W., LMSW-ACP 

Department of Sociology, Social Work, 

and Criminal Justice 

Southern Louisiana University 

Hammond, Louisiana 

Susan E. Hutchinson, Ph.D., LMSW-ACP 

The University of Texas-Pan American 

Edinburg, Texas 

ABSTRACT 

This paper describes a culture-specific model of 
violence against women of the U.S.-Mexico border 
region. A culturally relevant empowerment model 
of prevention and intervention for male perpetrators, 
battered women, and those who choose not to get 
involved are offered at the micro, mezzo, and macro 
levels of response. Barriers addressed include 
inappropriate and inadequate professional 
responses, inadequate ongoing support systems, and 
lack of adequate services. Collaborative responses 
to counter these are offered. Relevant cross-cultural 
comparisons with Nicaragua and Ghana are made. 

Background 

Violence against women is a raging cancer that 
gnaws at the heart and soul of the human family and 
transcends ethnic, socioeconomic, and geographical 
borders. However, the use of power and control 
tactics and exposure to violence in the family of 
origin have been shown to be significantly related to 
battering behavior in the community considered 
here. In addition, battered Latinas have been found 
to show reluctance to use battered women's services. 

Discussion 

In 1993, a national poll found that 34% of adults in 
the United States reported having witnessed a man 
beating his wife or girlfiiend (EDK Associates, 
1993). Studies suggest that 30% of all women 
treated in emergency rooms of hospitals have 
injuries or symptoms related to physical abuse 



(McLeer and Anwar, 1989). Domestic violence is 
the second most common cause of injury among 
women and the leading cause of injuries to women 
ages 15 to 44. Injuries to women due to domestic 
violence are more common than automobile 
accidents, muggings, and rapes combined. The 
perpetrator is usually a male intimate who feels 
threatened in some way; alcohol and guns are 
fi-equently involved (Novello, 1993). Two to four 
million women are beaten by their husbands or 
boyfriends each year. Of those so battered, 2,000 to 
4,000 will die fi"om their injuries (American 
Academy of Family Physicians, 1994). 

The National Crime Survey puts the annual medical 
costs of domestic violence at around 100,000 days 
of hospitalization, 30,000 emergency room visits, 
and 40,000 visits to a physician each year. 
Although as many as 35% of women who visit 
emergency rooms are there for symptoms related to 
ongoing abuse, as few as 5% are identified as such 
(Novello, 1993). 

Border populations represent diverse peoples. 
However, most of the women of the U.S.-Mexico 
border region see themselves as Mexican, Mexican- 
American, Hispanic, Latina, or Chicana. 

Although there is a lack of scientific investigation of 
domestic violence within the Latino community and 
about U.S.-Mexico border women, in general there 
is little reason to expect that rates in terms of 
incidence vary significantly fi"om more global 
assessments. 

Results 

Investigations completed thus far indicate that a 
significant relationship exists between the use of 
power and control tactics and battering behavior, 
and that exposure to violence in the family of origin 
is significantly related to battering behavior (Olona, 
1993). Also, battered Hispanic women were found 
to have knowledge of battered women's services and 
shelters but showed reluctance to use them (Flores- 
Shakouri, 1992). The researchers' finding of 
underuse of services suggests that these women had 
extensive social support networks that contributed 
to that low use (Flores-Shakouri, 1992). Clinical 
wisdom of persons serving U.S.-Mexico border 



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women would suggest that this is a gross 
oversimphfication of the matter. What is known is 
that, to some extent, oppressed women may not 
recognize domestic violence as abuse. For instance, 
Ghanian women characterize it as necessary for 
disciplinary purposes, to the extent it is socially 
"invisible" (Ofei-Aboagye, 1993). 

Future 

As with all social issues in all historical contexts, it 
is often left for the literary scholar to foresee, as if 
darkly in a glass, what will at some future time 
become clear through research. Gloria Anzaldua 
gives a moving account of the matter in her book 
Borderlands: La Frontera: The New Mestiza . 
Ms. Anzaldua is a native of the Magic Valley and 
was a student at The University of Texas-Pan 
American. We read her powerful words: 

5^ "You're nothing but a woman" means you are 
defective. Its opposite is to be "un macho". The 
modem meaning of the word "machismo," as well 
as the concept, is actually an Anglo invention. 
For men like my father, being "macho" meant 
being strong enough to protect and support my 
mother and us, yet being able to show love. 
Today's macho has doubts about his ability to feed 
and protect his family. His "machismo" is an 
adaptation to oppression and poverty and low self- 
esteem. It is the result of hierarchical male 
dominance. The Anglo, feeling inadequate, 
inferior and powerless, displaces or transfers these 
feelings to the Chicano by shaming him. In the 
Gringo world, the Chicano suffers from excessive 
humility and self-effacement, shame of self and 
self-deprecation. Around [educated] Latinos he 
suffers from a sense of language inadequacy and 
its accompanying discomfort; with Native 
Americans he suffers from a racial amnesia which 
ignores our common blood, and from guilt 
because the Spanish part of him took their land 
and oppressed them. He has an excessive 
compensatory hubris [and arrogance] when 
around Mexicans from the other side. It overlays 
a deep sense of racial shame. 

>- The loss of a sense of dignity and respect in the 
"macho" breeds a false "machismo" which leads 
him to put down women and even to brutalize 
them. Coexisting with his sexist behavior is a 
love for the mother which takes precedence over 
that of all others. Devoted son, "macho" pig. To 



wash down the shame of his acts, of his very 
being, and to handle the brute in the mirror, he 
takes to the bottle, the snort, the needle, and the 
fist. (p. 83) 

What Can Be Done 

If, for the sake of this discussion, we accept Ms. 
Anzaldua's assessment of the domestic violence a la 
frontera, what is to be done? Anzaldua herself calls 
for the following: 
>- A new consciousness won through taking 

inventory, putting history through a sieve, 

surrendering all notions of the familiar; if you 

will, a true coming to self. 
>> Working to understand the root causes of male 

hatred and fear, never condoning the wounding of 

women, refusing to put up with it and demanding 

that men cease hurtful put-down ways 
> Developing equal power; women supporting 

women 
>* A movement toward a new masculinity through a 

men's movement 
>* Allowing whites as allies, on conditions 
>* Demanding that whites admit to treating Chicanos 

as less than human, stole their lands, personhood, 

and self-respect 
>* Demanding that Anglos make public restitution, 

admit that their behavior was in compensation for 

their own sense of defectiveness. 

On a more practical level, how is this to be 
achieved? We suggest an empowerment approach. 
Empowerment is "a process of increasing personal, 
interpersonal, or political power so that individuals 
can take action to improve their life situation" 
(Gutierrez, 1990, p. 149). Empowerment is more 
than giving and more than enabling. It involves 
establishing a belief in the competency of informed 
persons to cocreate positive personal and social 
change. Here we distinguish between external 
empowerment (institutional, legal, and political) and 
internal empowerment (personal, intrapersonal, and 
interpersonal). 

External Empowerment 

External or macroempowerment interventions 
address social, educational, economic, and political 
realities. These target the laws and institutional 
structures in our society. External empowerment 
action in the realm of domestic violence against 
women would involve the following: 



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Procedures required of law enforcement officers who 
receive reports of domestic violence should be 
enforced. Any officer having probable cause, 
including visible injury, to believe assault occurred 
is now required to arrest. Those serving battered 
women know all too well this is not always carried 
out. 

5=* Firm no-drop ordinances that eliminate charges 
being dropped by victims once the perpetrator is 
out on bail and attempts coercion should also be 
enforced. The complainant becomes the police 
officer on behalf of civil order. When properly 
enforced, the victim is no longer choosing or 
refusing to press charges and/or testify. 

>* Resources should be allocated for adequate, long- 
term, quality sheltering services, including training 
for women who are unable to provide financially 
for themselves and their children should the 
perpetrator refuse treatment. 

>► Resources should also be allocated for adequate, 
quality treatment programs for perpetrators, 
victims, and the silent victims who are imwilling 
observers of violence in their homes. 

> Broad-reaching and in-depth public education 
programs should be established for the following: 

• very young children 

• health care providers 

• law enforcement and judicial personnel 

• the clergy 

• members of the legal profession 

• professional educators, prekindergarten through 
high school. 

This is quite a menu of external empowerment 
interventions. It is difficult to move the powers that 
be in our governing bodies— in county seats, in 
Sacramento, in Austin, in Washington. It is 
demoralizing for professionals working with abused 
border women, over and over again, to compile 
laundry lists of needed resources and structures to 
address a problem related to the health and welfare of 
border women, only to shelve it, or see it shelved by 
others. 

Internal Empowerment 

This is where personal (micro and mezzo) 
empowerment-oriented interventions come into play. 
On any social issue, enactment and enforcement of 
external prohibitions and penalties rise out of an 
empowered interest and constituency. No matter 
how much we seek to reduce or stamp out domestic 



violence against border women, we must accept that 
personal empowerment is a requisite condition. 

Personal empowerment is, however, a 
developmental process (Kieffer, 1984) and to 
succeed it must reflect and work within important 
cultural values and realities. Personal 

empowerment begins with the individual and small 
groups of individuals. It is based upon the 
competencies of self-esteem and motivation that 
allow the individual to engage in self-direction 
(Anderson, et al., 1994). 

Health and social services related to domestic 
violence would no longer focus on treatment of the 
victim/survivor alone, or even primarily. Primary 
focus would no longer be upon education for coping 
but would instead address problems in relation to 
the role of objective powerlessness that many border 
women face (Gutierrez, 1990). 

The first step in an empowerment approach 
addressing the problem of domestic violence and 
border women would be unveiling its realities, 
following the work of Paulo Freire (1994). This 
unveiling does not involve research projects, 
conventional educational programs, or treatment, 
but involves dialogue based on critical thinking 
between oppressed persons, changing the way they 
perceive the world of oppression. This process 
involves coinvestigation by participants, both of the 
objective situation and awareness of that situation. 
Abandoning silence and myth prepares participants 
for the struggle against the obstacles to their 
humanization (p. 100). Concientization is "learning 
to perceive social, political, and economic 
contradictions, and to take action against the 
oppressive elements of reality" (p. 17). 

The second phase of the empowerment process 
involves those same women freeing their oppressors 
(male batterers, Hispanic men who do not batter but 
give silent approval, Latinas who are not battered 
but have kith and kin who are and refuse to act, 
white men and white women who oppress). "It is 
only the oppressed who, by freeing themselves, can 
free their oppressors" (p. 42). Only in this way can 
we each and all come to grasp that domestic 
violence against border women is but one outcome, 
one manifestation, of racial and sexual and class 



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oppression at the border. 

Nicaragua 

The model offered here is not simply theoretical. 
Just such a process of reflection in action is taking 
place in Nicaragua where women have confronted 
the political culture of violence. This has, in turn, 
become a key factor in shaping the sfrategic position 
of women as citizens in that country. The struggle of 
Nicaraguan women against domestic^ violence 
provided a significant mechanism through which 
women articulated their gender and political 
identities (Dolan, 1993). 

Conclusion 

Gutierrez (1990) described four changes that occur in 
the movement of persons from apathy and despair to 
action — (1) increasing self-efficacy, (2) developing 
group consciousness, (3) reducing self-blame, and 
(4) assuming personal responsibility for change (p. 
150). This growth occurs within the context of small 
groups or small communities, with a focus on mutual 
aid, self-help, and support. 



To this end, one of the sfrongest and most valuable 
social institutions in the border area is called into 
play— the family. However, a broader definition of 
la familia is required. Through the process of 
concentization, described by Freire (1994), comes 
an awareness that all women are sisters. As long as 
one woman is at risk of uncensored violence, all 
women are at risk, all men are at risk, the family 
itself is at risk. Empowerment groups developed 
within this context allow a process of 
consciousness-raising that respects Latina rejection 
of conventional "white" feminism while embracing 
an empowering women's movement that honors 
cultural imperatives. 

If each genuinely conscious person in the border 
region mentored one battered woman toward 
personal empowerment for a full year, we could 
change the reality of this issue. If each genuinely 
conscious person in the border region started and 
followed for a whole year one self-help or support 
group dedicated to conscientization, we could 
change the reality of this issue. 



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REFERENCES 



American Academy of Family Physicians. Family 
violence: An AAFP white paper. American Family 
Physician. 1994;50(1639). 

Anderson SC, et al. Empowerment and social work 
education and practice in Africa. Journal of Social 
Development in Africa . 1994;9(71-86). 

Anzaldua G. Borderlands: La Frontera: The New 
Mestiza . San Francisco: Aunt Lute Books, 1987. 

Dolan JM. Gender, militarism, and the state in 
Nicaragua . Madison: The University of Wisconsin, 
1993. 

EDK Associates. Men beating women: Ending 
domestic violence— A qualitative and quantitative study 
of public attitudes on violence against women . New 
York: EDK Associates, 1993. 

Flores-Shakouri A. Reasons for low utilization of 
battered women's shelters among Hispanic women . 
Long Beach: California State University, 1992. 

Freire P. Pedagogy of the oppressed . New York: 
Continuum, 1994. 



Gutierrez LM. Working with women of color: An 
empowerment approach. Social Work . 1990;35 (149- 
153). 

Kieffer CH. Citizen empowerment: A developmental 
perspective. Prevention in Human Services . 1984; 
3(2/3):9-36. 

McLeer SV, Anwar R. A study of battered women 
presenting in an emergency department. American 
Journal of Public Health . 1989;79(65-66). 

Novello AC. American Medical News . March 23, 
1993;35:41. 

Ofei-Aboagye R. Addressing domestic violence in 
Ghana . Kingston, Canada: Queen's University at 
Kingston, 1993. 

Olona TC. An examination of predictors of domestic 
violence in Latino males . Los Angeles: California 
School of Professional Psychology, 1993. 



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DETECTION OF VIOLENCE 

AGAINST WOMEN THROUGH 

ORGAN-NEUROSIS 

DETECCION DE VIOLENCIA 

CONTRA LAS MUJERES 

A TRAVES DE LAS 

ORGANO-NEUROSIS 

Consuelo Maury de Santiago 

Investigacion Transversal con Analisis 

Retrospectivo 



ABSTRACT 

All illnesses are "psychosomatic," since no 
"somatic" affliction is completely free from 
psychological influences. When a woman suffers 
from intrafamily violence, generally, she endures 
emotional and physical mistreatment, but it is not 
easy for her to freely manifest this during the 
medical consultation (perhaps because of shame), 
and many times the physician does not specifically 
inquire (perhaps because of lack of awareness). In 
view of this difficulty, this project uses the 
symptomatology of organ-neurosis and a model of 
direct interrogation, which permits the 
"demystification" of somatic symptom and the 
"recognition" of the emotional suffering. The 
interrogation examines organ-neurosis— 

gasfrointestinal, muscular, genital-urinary, 
cardiological, neurological, and sexual function. 

Neurological symptomatology was most frequent 
among misfreated women 26 to 45 years old; 
urinary was most frequent in women from 16 to 35 
years old. On the other hand, the younger the 
woman, the less "complex" the system affected; for 
example, gasfrointestinal was the most frequent 
symptomatology of women 10 to 25 years old. In 
the refrospective study, it was shown that two of 



every three women interviewed using this model 
recognized being mistreated. 

Therefore upon inquiring specifically about 
psychosomatic symptoms, it is feasible to detect in 
a positive way the presence of emotional and 
physical misfreatment if this were the case; upon 
recognizing the problem, it was much simpler to 
sensitize the women and include them in therapy, 
which provides orientation and support in the search 
for alternatives. 

INTRODUCOON 

En las ultimas decadas las estadisticas han revelado 
que el lugar considerado mas seguro, a saber: La 
PROPIA CASA, era precisamente el sitio en el cual 
mas accidentes podrian ocurrimos. 

La violencia ha sido una especie de "OVEJA 
NEGRA," algo secreto y soslayado para las 
investigaciones y teorias de cualquier rama de la 
ciencia. 

Una verdad que nos queda clara a los profesionales 
que frabajamos en esta rama es que dependemos 
fundamentalmente de la VERBALIZACION del 
paciente; de ese "SI QUIERE o PUEDE 
HABLAR," porque la aceptacion le deja la 
impresion de vulnerabilidad y desproteccion. Por 
ofro lado, tambien la paciente necesita de un 
interrogatorio dirigido que le allane el camino y le 
permita abrirse sin temor y buscar asesoria y 
orientacion. 

Durante 1993, el Gobiemo del Estado de Coahuila, 
preocupado por el bienestar de su poblacion inicio 
una investigacion a fraves de la consulta popular 
observando que uno de los problemas menos 
atendidos son los referentes a la Mujer. Con esta 
ideologia, la Secretaria de Salud del Gobiemo del 
Estado de Coahuila abrio a la comunidad el 
CENTRO DE ATENCION A LA SALUD 
INTEGRAL DE LA MUJER, conocido 
popularmente por "SI MUJER." Su objetivo es 
proporcionar atencion a las mujeres que lo soliciten, 
a fraves de los servicios Psicologico, Medico y 
Legal, a fin de acrecentar, corregir y/o preservar el 
estado de Salud Integral de la Mujer. Realizamos 
acciones de asesoria, orientacion, consulta, 
tratamiento, algunas veces gestoria, enfocando las 



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El Departamento Medico del Centro "SI MUJER," 
inicio las investigaciones que permitieran 
proporcionar mejor atencion. Este trabajo fue 
preparado con la intencion de demostrar que muchas 
de las consultas extemas otorgadas a las mujeres, 
tienen como fondo un proceso de VIOLENCIA NO 
DETECTADO y que esta causando alguna 
alteracion organica que no se ha podido manifestar 
ya sea por falta de sensibilizacion del facultativo 
durante el interrogatorio o por factores especificos 
de la Mujer, que le impiden verbalizar la 
problematica real que sufre. 

La violencia contra la Mujer ha sido reconocida 
recientemente como un asunto de derechos humanos 
que tiene un profundo impacto sobre el bienestar 
fisico y mental de los afectados, pero ha recibido 
escasa atencion como tema de salud publica. 

En forma general, la violencia como causa de 
enfermedad ocupa el ultimo lugar en un listado de 
37 factores predisponentes de morbilidad 
designados por el Sector Salud Mexicano; sin 
embargo, ocupa segiin el sexo, el segundo y cuarto 
lugares en los grupos etarios de 15 a 44 aiios como 
causa de mortalidad general, respectivamente 
masculino y femenino, esto sin incluir el suicidio. 

Las mujeres mexicanas en general ocupan el 30% de 
las hospitalizaciones por violencia, mientras que 
representan el 64% de los encamados por 
enfermedades cronicas. 

Como motivo de consulta externa, la violencia ni 
siquiera es contemplada como impresion 
diagnostica, ni en forma de violencia intrafamiliar o 
como sindrome de Mujer Maltratada. 

Sigue siendo considerada como sintoma, no como 
enfermedad. 

JUSWICACION 

Todo aquel Medico que quisiera escuchar y pensar 

en funcion de algun pedacito de la Historia Clinica 

de su paciente, deberia sentirse obligado a 

considerar cual es la demanda oculta de sus 

consultas. 

De acuerdo a la propedeutica clinica, un 
interrogatorio bien dirigido basta para tener una 
impresion diagnostica del caso y la exploracion 



fisica solo reflitara o reforzara esta impresion; pero 
tambien sefiala que primero hay que descartar el 
factor organico para poder determinar que el motivo 
de la patologia es emocional. Hay que aclarar 
tambien que se requiere de experiencia y 
sensibilizacion por parte del Medico para poder 
tomar en cuenta todos los factores que intervienen 
en un proceso de enfermedad, entre ellos la 
violencia. 

Hay ocasiones, como en el Sindrome de Mujer 
Maltratada o de la Violencia Intrafamiliar, que las 
dos primeras premisas no son de utilidad primaria, 
a menos que los procesos hablen por si mismos, por 
e.j., equimosis visibles. 

Sin embargo, la historica clinica marcara en forma 
mas o menos precisa que el factor de violencia esta 
produciendo secuelas daninas. 

Al realizar una revision retrospectiva de los 
expedientes clinicos, observe que generalmente 
pasaban entre dos a tres consultas antes de que la 
paciente verbalizara en forma clara e hiciera la 
relacion directa entre lo que le afectaba y su modo 
de vida, esta relacion siempre conllevaba un 
proceso de violencia. Observe tambien que en la 
mayoria de las consultas se trataban de una organo- 
neurosis. 

En base a lo anterior, llegue a la conclusion de que 
el proceso de deteccion era mas dificil de lo que se 
pensaba y se ideo un instrumento por el cual el 
proceso de deteccion fuera mas sencillo y permitiera 
ubicar a la paciente desde la primera consulta. 

MaterialesY Metodos 

Se tomo el interrogatorio por aparatos y sistemas de 
la historica clinica y se mezclo con los elementos 
que se marcan en el circulo de violencia de poder y 
control, creandose un interrogatorio mixto. 

Este formato de interrogatorio comun se aplicaria a 
aquellas pacientes que solicitaran consulta por 
primera vez y que negaran durante el proceso de 
apertura de expediente, haber sufrido violencia. El 
modelo de abordaje que se ideo permitio 
"enmascarar" un interrogatorio especifico de 
violencia, brindandole a la mujer la idea de que era 
un interrogatorio clinico, ademas le proporciona a la 



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violencia, brindandole a la mujer la idea de que era 
un interrogatorio clinico, ademas le proporciona a la 
paciente la confianza suficiente para hablar del 
tema. 

El formato se dejo abierto, ya que se tomaban las 
preguntas de acuerdo al motivo de consulta de la 
paciente y de las vivencias de la persona, pero 
siempre eran tomadas de los ocho factores que estan 
marcados en el circulo de control y poder. 

Estudio flexible, transversal y con duracion de 5 
(cinco) meses; su objetivo: observar cuantos casos 
positivos de violencia se detectaban por este medio. 

Los requisitos que se solicitaban para integrar a una 
paciente en el estudio eran los siguientes: 

> Solicitar consulta Medica. 

>* Que durante el proceso de apertura de expediente, 

por admision, negara sufrir violencia. 
>* Que fuera usuaria de primera vez. 

> Que NO tuviera evidencias fisicas del maltrato. 
>- Que NO hubiese tenido contacto anterior 

con los Deptos. de Psicologia y/o Legal. 

Durante el interrogatorio de la Historia Clinica, 
dentro de los antecedentes personales, debia negarse 
la violencia, y se tomaban en cuenta todos los tipos 
de maltrato, fisico, emocional y/o sexual y podia ser 
de Padres a Hijos, de Esposo a Esposa, de Novio a 
No via, etc. 

Al llegar al interrogatorio por aparatos y sistemas, 
despues del padecimiento actual, se ubicaba el 
padecimiento. Si este correspondia a los datos 
psicosomaticos, se utilizaba el modelo de abordaje. 
>" Por ejemplo: 

> Propedeutica: ^Tiene altemancia en la 

consistencia del excremento? 
>" Violencia: ^Esto le sucede 1 o 2 dias despues 
de tener algiin altercado familiar? 

La primera pregunta lleva por objetivo determinar 
la presencia de colon irritable, la segunda relacionar 
el proceso. 

^^ Propedeutica: iCon que frecuencia tiene Ud. 
relaciones sexuales? 

> Violencia: ^ Recibe Ud. presion u 

hostigamiento para consentir en 
tener relaciones sexuales? 

La primera determina el ejercicio de la sexualidad, 

la segunda el abuso sexual. 



5=* Propedeutica: ^Se forman facilmente 
"moretones" en su piel? 

>* Violencia: ^En alguna ocasion la ha golpeado 

su pareja? 

La primera determina fragilidad vascular, la 

segunda maltrato fisico intencional. 

5> Propedeutica: ^Que tipo de alimentacion 

consume? 
>* Violencia: ^Quien determina como se debe 

gastar el dinero en casa? 

La primera pregunta tiene como objetivo determinar 
el estado nutricional; la segunda, el abuso 
economico. 

Cuando la segunda pregunta resultaba positiva, se 
profundizaba en la busqueda de informacion. 

Cuando se tenian mas de tres sintomas positivos en 
el circulo de violencia y la patologia principal o la 
causa de la consulta era de indole psicosomatica, se 
iniciaba la desmitificacion del sintoma, por ej.: 

5*^ SRA., Ud. menciona que tiene problemas para 
conciliar el sueno, que tiene estreiiimiento y 
meteorismo, alteraciones en la consistencia del 
excremento y aparte se le olvidan las cosas; 
entonces digame: ^CON QUIEN ES EL 
PROBLEMA EN CASA?. 

Generalmente este tipo de interrogatorio 
deconcertaba a la paciente, produciendo que 
verbalizara la situacion que mantenia en el interior 
de su casa; al ocurrir esto, iniciabamos una atencion 
normal de un Centro de Atencion en Violencia, 
independientemente de que proporcionaramos 
tratamiento medico. 

Este tipo de "cierres" en la entrevista producia crisis 
de llanto y permitia el desahogo de la 
paciente, estableciendose una apertura de confianza 
benefica para el proceso de atencion. 

Resultados 

De Agosto de 1994 a Febrero de 1995, se realizaron 
157 interrogatorios con este modelo, encontrandose 
los siguientes resultados. 

De los 157 interrogatorios, 117 (74.52%) 
resultaron positivas a la deteccion de violencia, de 
estas el 49% (58) mencionaron agresion fisica 
directa por lo menos en una ocasion. En todas las 



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detecciones positivas, los examenes de laboratorio 
posteriores resultaron negatives para el cuadro que 
reportaban; sin embargo, se detectaron otras 
patologias organicas no referidas, como cervico- 
vaginitis en donde el 34% relacionaban sus cuadros 
infecciosos con el comportamiento inadecuado de 
supareja. 

El 31% (49) de las mujeres correspondian al grupo 
etario de 16 a 25 alios, el 25% (40) al de 26 a 35 
anos, siguiendole el de 36 a 45 anos con el 18%» (29) 
y el 14% (22) correspondia al de 46 a 55 anos. 

Por semiologia de aparatos y sistemas fue mas 
frecuente el Sistema Nervioso Central (SNC) con el 
83.72% (131). 

La sintomatologia digestiva fiie positiva en el 43% 
(68), el 36% (56) referian sintomatologia 
cardiorespiratoria, 30.23% (47) el sistema genital y 
el 20% (32) con el Urinario, 18% (29) positivas en 
Oseo- Artro-Muscular y el 10.82%) (17) con datos 
en el sistema de piel y faneras. 

La mayor frecuencia de presentacion por grupo de 
edad y sintoma principal fue asi: 10 a 25 aiios: 
Digestive; 26 a 45 anos: Nervioso; 16 a 35 anos: 
Urinario; 35 a 55 anos: cardiorespiratoria; 16 a 35 
anos: Genital; 26 a 45 aiios: Oseo-Artro-Muscular; 
y de 10 a 35 anos: Piel y Faneras. 

Los desordenes psicosomaticos mas frecuentes 
fiieron: Migrana, Insomnio, Colon Irritable, 
Gastritis, Disfuncion Sexual, Lumbalgia, Algias 
precordiales no anginosas. Dermatosis, Ostitis y 
Asma. Hay que hacer mencion de cuatro casos de 
paralisis facial infranuclear, tres relacionados con 
situaciones directas de violencia intra-familiar y una 
con Sindrome de Mujer Maltratada. 

De las 117 pacientes que se detectaron positivas, 
casi las tres cuartas partes present© crisis de llanto 
y declaraban sentirse mucho mas tranquilas al poder 
hablar con alguien de lo que les estaba pasando. 

El hecho de encontrar laboratorio negative 
correberaba que muchas de las sintematologias se 
podrian considerar de indole emocional. 

El 62% del total de las entrevistadas recibio 
tratamiento psicologico y farmacologico. El 38% 



solo recibio tratamiento psicologico, algunas de las 
cuales tedavia continiian baje terapia. 

DISCUSION 

La literatura reporta que en los desordenes 
psicosomaticos, la paciente reacciona al estres, a la 
tension y a la ansiedad con un mal funcionamiento 
directo. Cuando el enojo se puede expresar con una 
accion directa en forma intensa, se provoca una fuga 
inmediata, con esta reaccion se disipa y consume la 
energia movilizada en las reacciones viscerales. Sin 
embargo, de no haber salida posible, de no haber 
expresion o accion, los cambios viscerales 
persistiran. Al no tener alivio a la tension, se 
producen una amplia gama de alteraciones 
fisiologicas. 

Cuando este tipo de sucesos se vuelve cronico y 
ocurre en repetidas ocasiones, los cambios 
viscerales sobrepasan los limites normales, se 
vuelven patologicos y se pueden producir 
desordenes psicosomaticos; en otras palabras, hay 
cambios organicos producidos por el manejo 
inadecuado de las emociones. 

El matiz oscilante de los desordenes psicosomaticos 
se adapta en perfecta forma al Sx De Mujer 
Maltratada o de la Violencia Intrafamiliar, porque el 
proceso del estres se prolonga en tiempo y se eleva 
en gravedad, creando una situacion de circulo con 
respecto a las reacciones viscerales, muchas veces 
por la contencion de las emociones y otras por el 
exceso de manifestaciones. 

Por lo tanto, conforme se prolonga la problematica 
de violencia inician su aparicion las organo- 
neurosis. De acuerdo a esto, todas las que 
resultaron positivas a la deteccion, tenian mas de 
dos anos de evolucion, incluso algunas presentaban 
mas de 10 aiios. 

Un porcentaje muy alto de las pacientes 
interrogadas (67%)) mencionaban que habian 
decidido recurrir a la consulta porque sus parejas o 
sus padres se lo aconsejaban: "ve a ver al Medico a 
ver si te pueden "arreglar," porque siempre te 
duele algo". Si la mujer no esta convencida de que 
su proceso de enfermedad tiene relacion con su 
modo de vida familiar, normalmente no lo 
mencionan. 



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Se observe que el grupo mas frecuente que se 
interrogo flie el de 16 a 25 anos, esto se derive de 
los requisites de la investigacion. Normalmente se 
observe que a las mujeres de mayor edad no les 
resultaba dificil aceptar que tenian preblemas en el 
interior de su familia, situacion que no se da en el 
grupo etario que nos ocupa. 

Sabemes de antemano que el mantenimiento del 
vinculo violento no es casual, ni producto de una 
estructura sadomasoquista, sino que se instaura a 
traves de un ciclo que se refuerza a si mismo. Las 
organo-neurosis comienzan protegiendo al paciente 
de algo peor, comienzan siendo adaptaciones, no 
importa que camino tomen despues. La teoria 
Freudiana menciona, que los desordenes 
psicosomaticos son la expresion de una fantasia en 
"lenguaje corporal," otros autores mencionan que se 
tienen funciones que le proporcionan al paciente 
alivio, por ej. : 1) Pone en lugar de una situacion 
intolerable una enfermedad real o aparente, 2) Le 
dan al paciente los privilegios otorgados a una 
persona enferma y/o 3) Les permite utilizar su 
enfermedad fisica como medio para obtener interes, 
cuidado y afecto. 

Dentro del circulo de control y poder de la violencia 
observamos el reforzamiento continue a base del 
sometimiento, por lo que la expresion de las 
emociones y la toma de decisiones esta 
obstaculizada; esto generara a la larga reacciones 
viscerales no desahogadas y con ello la aparicion de 
sintomas psicosomaticos. 

Al revisar la patogenia del Sindrome de Mujer 
Maltratada y la de las Organo-neurosis, ^No cree 
Ud. que son patologias complementarias?, entonces, 
^por que no utilizar a una para descubrir a la otra? 

El 100% de las mujeres interrogadas mencionaron 
que habian visitado anteriormente a otros 
facultativos, pero que ninguno las habia 
encuestado de esta forma y que en ocasiones la 
habian referido en las consultas, pero que se les 
habia pasado por alto esta informacion. No hay 
que descartar que al acudir a la consulta en el 
"SI MUJER", que entre la poblacion es 
conocido por su actividad especial, haya 



influido en que algunas de las detecciones 
resultaran positivas. 

En el analisis complete de les resultados hay 
muchos mas dates que se pueden destacar, pero el 
objeto era prebar el modele de abordaje, el reste de 
resultados se manejaran en etro reporte. 

CONCLUSIONES 

>- El interrogatorio por aparatos y sistemas de 

la Historia Clinica es lo bastante flexible como 

para permitir la biisqueda de informacion. 
>* Es posible detectar en forma positiva a la 

Violencia en contra de las Mujeres a traves de los 

desordenes Psicosomaticos. 
>> Que la Violencia contra la Mujer SI puede ser 

considerada como un factor predisponente de 

Enfermedad Organica. 
s^ Que ninguna encuesta, Deteccion o 

Interrogatorio es Definitiva y Completa. 
5^ Que la Violencia SI puede ser CAUSA de 

Consulta Medica por lo que seria factible 

considerarla como IMPRESION 

DIAGNOSTICA. 



DETECCION DE 

VIOLENCIA CONTRA LAS MUJERES 

A TRAVES DE 

LAS ORGANO-NEUROSIS 



DRA. CONSUELO MAURY DE SANTIAGO 

TORREON, COAHUILA, MEXICO. 
1995 



La Violencia Como Diagnostico 



OCUPA ELULTIMO 

LUGAR DE 37 CAUSAS 

DE MORBILIDAD EN EL 

SECTOR SALUD. 



ES2aA4aCAUSADE 

MORBILIDAD GENERAL 

EN LOS GRUPOS ETARIOS 

DE15A44ANOS. 



INECH 



INBCH 



LAS MUJERES MEXICANAS REPRESENTAN EL 

30% DE LAS HOSPITALIZAQONES POR VIOLENCIA 

Y EL 64% POR ENFERMEDADES CRONICAS. 



MOJERESIAT[NQAMERICANASG» OFRAS, 
VOL. MEXICO. 

EN UV CONSULTA EXTERNA NO ES CONSIDERADA 
NI SIQUIERA COMO IMPRESI6N DIAGN6SnCA. 



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11 



ANTECEDENTES 
HEREDOFAMILIARES 



INTERROGATORIO 

POR APARATOS Y 

SISTEMAS 



EXPLORAC. FISICA Y 

MfeTODOS 
COMPLEMENTARIOS. 




ANTECEDENTES 
NO PAT0L6GIC0S 



ANTECEDENTES 
PATOL6GICOS 



fr 



PADECIMIENTO 
ACTUAL 



EL INTERROGATORIO POR 

APARATOS Y SISTEMAS 

SE MEZCLO 

CON UN INTERROGATORIO DEL 

CmCULO DE VIOLENCIA 

(PODER Y CONTROL), 

SE APLICO A MUJERES QUE 

ACUDIAN A CONSULTA POR 

PRIMERAVEZ 



Son Patologias Complementarias 




POR QUE NO UTILIZAR 

A UNA PARA DESCUBRIR 

A LA OTRA 



REQUISITOS: 

>■ Usuaria de primera vez 

>* Haber solicitado consulta exclusivamente 

>> Haber negado u omitido el antecedente de violencia en la apertura del expediente. 




FuNCiONES De Las Organo-neurosis 



EN LUGAR 

DEUNA 

SITUACION 

INTOLERABLE 

HAY UNA 

ENFERMEDAD 

REAL 

O 

APARENTE 



PROPORCIONA 

AL PACIENTE 

LOS PRIVILEGIOS 

OTORGADOS 

A UNA 
PERSONA 
ENFERMA 



PERMITE 

UTILIZAR 

ALA 

ENFERMEDAD 

FISICA 

COMO MEDIO 

PARA OBTENER 

INTERES, 

CUIDADO Y 

AFECTO 



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Resultados 



DETECCIONES 
POSITIVAS 




> 



EXAMENES DE 
LABORATORIO 



(58) 49.5% REPORTARON 

AGRESION FISICA POR LO 

MENOS EN UNA OCASION. 

72% REPORTABAN ALGUN 

TIPO DE DISFUNCION SEXUAL, ~ 

34% RELACIONABAN CUADROS 

DE CERVICO-VAGINITIS INFECC. 

CON UN COMPORTAMIENTO INADECUADO 

DE LA PAREJA. 




NEGATIVOS 



Resultados 

Del 8 de Agosto de 1994 al 25 de Febrero de 1995. 157 Interrogatorios 



09 




C3 




-o 


120 


ct 




M) 




O 

u 


100 


u 




« 




-<-> 




fi 


80 


NN 




09 




U 




1m 


60 


« 




•^ 




9 




S 


40 


« 




Q 


20 


o 




Z, 







POSITIVAS 
NEGATIVAS 



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MODELO DE INTERROGATORIO 



SISTEMA DERMICO : 

PROPEDEUnCA : ^SE FORMAN FACDLMENTE 
MORETONES EN SU PIEL ? 
VIOLENCIA :^EN ALGUNA OCASION LA HA 
CX)LPEADO SU PAREJA? 



SISTEMA GENITAL; 

PROPEDEUTICA : ^CON QUE FRECUENCIA TIENE 

RELACIONES SEXUALES ? 
VIOLENCIA : ^SU PAREJA LA PRESIONA PARA 

CONSENim EN TENER RELACIONES 

SEXUALES? 



Resultados 

157 Muieres Interrogadas 





w 




cs 




U 


•o 


(4 


C3 


N^ 


o 


a 




M 


<u 


(4 


■M 




a 


u 


HH 


a 


in 

2 




i> 


> 


s 


e 


O) 


a 


Q 




o 





u 



90 



80 



70 



60 



SO 



40 



30 



20 



10 



/ J 


./ 




./ 




./ 




-/ ^ 








/ 




VI Ji 

^1 1 ^^F^l 


■/ i 


/ 1 


u 


u 



■ 


10A15ANOS 


■ 


16 A 25 ANOS 


■ 


26 A 35 ANOS 


■ 


36 A 45 ANOS 


m 


46 A 55 ANOS 


■ 


56 A 65 ANOS 


■ 


66 6 MAS 



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RESyiJADOS 

[J SNC 

^^m 26A45ANOS 
^11^^^(131) 83.7% 

MI Sfntomasmas 
HI ficcuentes: 
•^ MGRANAE 
EvBOMMO 



Resultados 




mGEsnvo 



10A35ANOS 
(68)43% 



SindronEiiBS frscuente: 
OOjCNIRRrrAHEY 
GASIRmS. 




36A65ANOS 



(56)36% 



Sintoma mas frecuente: 
ALOAS PRECDRDIALES 
N0ANC3N0SAS. 




16A35ANOS 
(32) 20,9% 



Sintoma mas frecuente: 

asrras. 



Resultados 



Resultados 




GEME4L 

16A35AN36 
(47)302% 
SfctonBmasT 
nSFUNQC^NSEXLlALY 
EK^OIMASIVENSIRLIALES 



HELYFAINEKAS, 

10A35ANDS 
(17)1082% 




OSEO ARTROMUSdlLAR 

26a45ANOS(29)1805% 

Sintoma mas frecuente: 
LUMBALGIAY 
ARTRALGIAS DIVERSAS. 



SntdiBriBS fiecuerte: 
lEM^aOSlS 



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BIBLIOGRAFIA 



Amat, G.B. (1995). "Mejorar la calidad de vida," en 
OBGYN, revista de ORGANON Laboratorios, sobre 
Mujer y Salud. Vol. VI: 7. 

Burin, M. "El Malestar de las Mujeres. La tranquilidad 
recetada," ED. PAIDOS, Madrid, Espafla. 1990. 

Cameron, N. "Formacion de Sintomas," en 
DESARROLLO Y PSICOPATOLOGIA DE LA 
PERSONALIDAD, DE: TRILLAS, Boston, USA 1989. 
Desordenes Psicosomaticos Op. Cit. 

Camvac (Centro de apoyo a Mujeres Violadas, A.C.), 
"Carpeta de Informacion basica para la atencion 
solidaria y feminista a Mujeres Violadas." Mexico, 
D.F. 1990. 

Briere, J. And M. Rustz, "Post Sexual Abuse Trauma: 
Data and implication for clinical practice," Journal of 
Interpersonal Violence, 2:367/79, 1987. 

Corsi, J. "Violencia Intrafamiliar, una mirada 
interdisciplinaria sobre un grave problema social," 
Compilador. ED. PAIDOS, Mexico, 1992. 

Fenichel, O. "Organo-neurosis" en Teoria Psiconalitica 
de las Neurosis. Editorial INTERAMERICANA, 
Madrid, Espaiia, 1991. 

Flacso (Facultad Latinoamericana de Ciencias 
Sociales), "Mujeres Latinoamericanas en cifras," Vol. 
MEXICO, Editado por el Instituto de la Mujer, 
Santiago de Chile, 1995. 

Gabone, M, "Conceptos y controversias en el manejo 
Medico del Sindrome de Intestino irritable," en 
Memorias del Simposium Intemacional de Sindrome de 
Colon Irritable, Unidad de Congresos Siglo XXI, 
Mexico, D.F. 1994. 

Galdston, R. "Violence begins at home: The parents 
center project for the study and prevention of child 
abuse," Journal Amer. Acad. Child Psychist. 
10:336/350, 1971. 

Heise, L. "Violencia contra la Mujer: La carga oculta de 
Salud," Organizacion Panamericana de la Salud, 
Washington, D.C. 1994. 

DOMESTIC ABUSE INTERVENTION PROJECT, 
"The Power and Control Circle," Dubuth, Minnesota, 



USA. Publicado por TEXAS COUNCIL ON FAMILY 
VIOLENCE. 

I.N. E.G. I (Instituto Nacional de Estadistica, Geografia e 
Informatica). Informacion Estadistica del Sector Salud y 
Seguridad Social, Cuademo No. 11, Mexico, D.F. 1993. 

Kvito, L. "La Violacion: peritacion medico-legal en las 
presuntas victimas." Editorial TRILLAS, Mexico, D.F. 
1991. 

Giberti, E. "Mujer, Enfermedad y Violencia en Medicina. 
Su relacion con los cuadros psicosomaticos", en la Mujer 
y la Violencia Invisible. Editorial SUDAMERICANA, 
Buenos Aires, Argentina. 1989. 

Nordase, J.J. "Sociologia", Trigesima primera 
reimpresion de la quinta edicion, GPO. Editorial 
SAGROLS, Mexico, D.F. 1989. 

McLeer, S.V. "A study of battered women presenting in 
an emergency department" AMERICAN J. OF PUBLIC 
HEALTH, 79:65/66.1989. 

Olona, TH. C. "An examination of predictors of domestic 
violence in Latino males." Los Angeles, Calif School of 
Professional Psychology, 1993. 

Montgomery, L.E. and Carter-Pokras, O. "Health status 
by social class and /on minority status: Implication equity 
research." Report from EPA/NEIHS/ATSDR, 1992. 

Manu, P. "Somatization disorder in patients with chronic 
fatigue syndrome." J. CLIN. PSYCHOSOMATICS, 
1989: 30:388/95. 

Lewis, G. "The epidemiology of fatigue: more questions 
than answers." J. EPIDEMIOLOGY C. HEALTH 1992; 
46:92/97. 

Alaide Foppa, A.C. "Mujer: Violencia-Salud en Mexicali, 
Baja California", Reporte de investigacion IMSS, 
avances de investigacion, 1995. 

Saenz, B.C. and Wessely, S. "Sobre el Sx Premenstrual. 
Sexismo y categorias diagnosticas" en Sobre Mujer y 
Salud Mental, Editorial EL SOL. Barcelona, Espana. 
1988. 

Suroz, "Semiologia Medica y Tecnicas exploratorias," 
SAL VAT EDITORES, septima Edicion, Barcelona 
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Walker, L. "The Battered Women," Harper Colophon Anojin, PK. "La inhibicion interna como problema de 

Brooks, New York, 1992. fisiologia," JOURNAL MEDICUS SOVIETICS, 1958. 

Tinbergem, N. "The study of instincts," Oxford 
University Press, London, 1971. 



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IDENTIFICATION OF THE 

INCIDENCE OF DOMESTIC 

VIOLENCE AMONG WOMEN 

USING HEALTH SERVICES 

IDENTIFICACION DE LA 

INCIDENCIA DE LA VIOLENCIA 

DOMESTICA EN LAS MUJERES 

QUE ASISTEN A LOS 

SERVICIOS DE SALUD 

Maria Concepcion Guzman Salazar 

Adriana Lara Valencia 

Elsa Babra Ramirez 

Grupo Feminista Alaide Foppa 

Social Work Division of the Mexican Social 

Security Administration 

University of Denver 

ABSTRACT 

The purpose of this project was to gather first-hand 
information regarding the incidence of domestic 
violence and its effect on women's health. It is the 
authors' hope that making public the results of the 
study will serve to increase efforts to promote 
training programs and prevention efforts to deal 
with the effects of domestic abuse on women's 
health. 

One hundred and six women ages 20 to 39 years 
were interviewed, of which 56.6% were seeking 
OB/GYN care and 2.7% primary care services. Of 
this group, 37 women reported being victims of 
domestic abuse. When the women were questioned 
if the violence was physical, psychological, or 
sexual, the number of cases increased to 52. Only 
11% of the women had reported the violence to the 
police, and only 10% had discussed the violence 
with a family member or fHend. Some 26% of the 
women reported suffering depression. A 
relationship between domestic violence and 
psychosomatic illness was observed. 

PRESEHJAOdH 

El Grupo Feminista Alaide Foppa, A.C., con la 



colaboracion del Departamento de Trabajo Social del 
Institute Mexicano del Seguro Social emprendio la 
tarea de generar informacion sobre la presencia de la 
violencia domestica en la mujeres que acuden a sus 
servicios, con el interes de conocer en primera 
instancia la frecuencia de esta y su relacion con la 
salud de las usurias. 

Los resultados del presente proyecto son alentadores 
al permitimos detectar la violencia^ de genero en las 
mujeres entrevistadas, como percibe la mujer la 
violencia en relacion a su estado de salud-enfermedad, 
cual es la sintomatologia mas frecuente y cuales son 
los servicios medicos que se otorgan en cada caso, 
valiosa informacion para proponer una adecuada 
prestacion de los servicios y mejorar la calidad y 
calidez de la atencion a la "MUJER 
MALTRATADA." 

Al dar a conocer los resultados pretendemos contribuir 
a ampliar las altemativas de coordinacion del sector 
oficial con otros organismos para promover 
programas de capacitacion, orientacion y de 
prevencion con el tema " salud- volencia" en la 
poblacion en general y de la mujer en particular. 

El Grupo Alaide Foppa agradece a cada uno de los 
participantes su colaboracion. 

JUSWICACION 

La preocupacion por reconocer y hacer explicita la 
violencia de genero como un problema social y por 
ende de salud publica; la necesidad de sensibilizar a la 
poblacion en su conjunto sobre las particularidades de 
que la violencia de genero es un problema sumamente 
complejo que incluye factores socioeconomicos y 
culturales que afectan el quehacer social de la mujer 
como ser humano sin importar clase social, ocupacion 
u estado civil, y, que podemos cambiar. 

El no tener la informacion cuantitativa y cualitativa 
que permita conocer y analizar las caracteristicas del 
fenomeno, asi como su frecuencia e impacto en la vida 
productiva y reproductiva de la mujer; la indiferente 
atencion legal, medica o psicologica a la victima de 
violencia y la falta de una infraestructura social y las 
condiciones materiales para su atencion con una 
vision de genero, nos motivo a realizar un esfiierzo de 
investigacion sobre la incidencia de la violencia 
domestica-salud en mujeres que asisten a los servicios 



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de salud; y, paralelamente, sistematizar la 
informacion sobre la violencia domestica que se 
denimcia en algunas agendas del ministerio publico 
de esta ciudad. 

Al respecto comentaremos que en Mexicali se 
avanza lentamente en la atencion a la victima de 
violencia sexual y se ha quedado a la zaga la 
violencia domestica, que se refleja al contar con 
ciertas estadisticas sobre la violencia contra la mujer 
siempre con referencia a la violencia sexual y pocos 
datos que permitan hablar de la incidencia de la 
violencia domestica y aun no contamos con 
estadisticas o estudios que permitan investigar la 
relacion entre violencia domestica y la salud. 

Por esta razon, consideramos que la investigacion 
que se realiza en esta area sera de vital importancia 
para la elaboracion de propuestas de accion 
efectivas, en la atencion a victimas de la violencia, 
en los programas de asistencia y seguridad social 
adecuados a la problematica de genero; ademas, 
patentizar el concepto de "MUJER 
MALTRATADA" en las leyes y reglamentos de 
salud, asistencia social, derecho civil y derecho 
penal a nivel local. 

Objetivo del Estudio 

Ob jetivo Genera 

Identificar la incidencia de la violencia domestica 
en la mujer que acude a los servicios de salud con el 
proposito de generar informacion para politicas 
efectivas en la prestacion de los servicios a la 
victima de la violencia y proponer proyectos y 
programas para su atencion. 

Objetivos Especfficos 

>- Identificar por medio de una muestra 

representativa de las mujeres que asisten a los 
servicios de salud en las unidades del I.M.S.S. la 
incidencia de la violencia domestica. 

>- Protocolizar el proyecto de investigacion ante el 
I.M.S.S. para la capacitacion del personal de 
trabajo social y medico. 

>* Sensibilizar al personal de trabajo social y area 
medica sobre la importancia de identificar los 
posibles casos de violencia domestica y/o abuso 
en el entomo familiar. 

>- Realizar vm primer acercamiento a la relacion 
violencia domestica-sintomas y enfermedades. 



ACERCA DEL METODO 

El esquema de investigacion se elabora en funcion de 
dos aspectos del marco de referencia: a) teorico: 
referente a las teorias que versan sobre el tema de 
violencia domestica, el marco conceptual de los 
Derechos Humanos y de la corriente de medicina 
psicosomatica, y b) metodologico: referente al metodo 
y tecnica mas apropiados en relacion a la aplicacion 
de encuestas por muestreo para identificar la 
incidencia de la violencia domestica-salud. 

Marco Teorico 

En este context© referiremos la violencia domestica a 
partir de los postulados y filosofia de los Derechos 
Humanos para definirlo como un hecho social y 
conceptualizar el termino de violencia desde el punto 
de vista sociologico con el proposito de precisar y 
concretar los elementos que integran la violencia 
domestica. Asimismo, en el analisis del binomio 
salud-sociedad la relacion intrinsica de ambos, nos de 
elementos que se relacionen en el proceso de bienestar 
fisico y mental de la mujer, en donde los factores 
naturales y sociales inciden en sus condiciones de 
enfermedad y calidad de vida. 

Al respecto, la investigacion dara respuesta a las 
siguientes interrogantes: 

>* ^Como se refleja y afecta en la salud de la mujer la 

violencia domestica? 
>- ^Existe algima relacion entre la violencia domestica 

y las enfermedades psicosomaticas que presentan las 

mujeres? 
>* ^Podremos detectar la presencia de la violencia 

domestica en las mujeres que asisten a los servicios 

medicos de la clinica 3 1 del I.M.S.S.? 
>- ^Cual es la firecuencia de esta? 
>- i,C6mo percibe la mujer la violencia? Y ^Como la 

relaciona con su estado de salud-enfermedad? 
> ^Cuales son la politicas institucionales de atencion a 

la salud y seguridad social de la mujer maltiatada? 

Resultados y Conclusiones 

Resultados 
Como se menciono con anterioridad, la muestra se 

integro de 106 entrevistas en mujeres que acuden a los 

servicios medicos del I.M.S.S., con especial enfasis en 

detectar la incidencia de la violencia domestica en las 

ususarias de dichos servicios. 

Las caracteristicas generales de las mujeres 

entrevistadas se presentan en los cuadros del 1 al 4 



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que en resumen muestran lo siguiente: 

POR GRUPOS DE EDAD TENEMOS: 
>■ 20.8% son mujeres de 20-24 anos 

> 18.0% son mujeres de 25-29 anos 
>* 1 8.9% son mujeres de 30-34 anos 

> 1 8.0% son mujeres de 35-39 anos 

SEGUN ESTADO CIVIL 
>■ 63.2% son casadas 
5> 23.6% Union libre 

SEGUN GRADO DE ESCOiARIDAD 
>■ 32.1%) Secundaria completa 
>► 22.6%) Tecnica 

> 15.1% Primaria completa 

Asi, tenemos que el 92.4% de las entrevistadas son 
mujeres en edad reproductiva, de las cuales el 
86.7% vive con su pareja, 7% son solteras; 
divorciadas y viudas son un 5% y 1% 
respectivamente. Asimismo, el 47% se dedica al 
hogar y el 53% realiza diferentes actividades entre 
las que destacan: 

SEGUN OCUPAOdN 

> 47.1% Hogar 

> 31.1%)Empleada 

> 11.3%0brera 

TlPO DE SERViaO DE SALUD AL QUEACUDEN 

> 56.5%) Gineco-obstetrico 

> 2 1 .7%) Medico familiar 

TlPO DE ENFERMEDAD QUE REPORTAN 
>- 38.6% Obstetrica 
>- 23.5% Ginecologica 

Como podemos observar, al ser la clinica 31 una 
unidad de especializacion la mayor parte de las 
pacientes refieren este tipo de servicio; mientras que 
en menor porcentaje reportan servicio de medicina 
primaria a nivel de medico familiar de la siguiente 
manera: 



>► 


8% infecciones respiratorias 


>► 


8% gastritis 


> 


6% paridad satisfecha 


>► 


5% artritis 


>► 


4%IVU 


>► 


3% cronico degenerativas 



En si, estas caracteristicas generates de la poblacion 



encuestada guardan similitud en el comportamiento 
estadistico con los reportes del I.M.S.S. 

En cuanto a la incidencia de la violencia domestica 
los datos se reportan en terminos generates de las 106 
encuestadas, son violentadas 37 mujeres, de las cuales 
el 30% vive con su pareja, el 3% son divorciadas; y, 
por ultimo, 2% son solteras. Con un grado de 
escolaridad de secundaria y media superior en un 
rango de edad de 25-39 anos sieudo su ocupacion 
principal el hogar y empleada. 

Sin embargo, al preguntar sobre los tipos de violencia 
ejercida, ya sea esta fisica, psicologica o sexual, el 
niimero de casos de la muestra se incremento a 52 
personas que no habian percibido el abuso sexual, la 
violacion o el maltrato psicologico como una 
violencia de genero. 

De las mujeres que ban sufrido violencia solamente el 
11% lo ha denunciado ante el ministerio publico y 
solamente el 10% lo comento con un familiar y/o 
amistades. Las razones para no denunciarlo son 
diversas, siendo las mas frecuentes "es un castigo por 
lo que hice," "no sabe," "no lo entiende," "por 
vergixenza." 

Al preguntar si sufren algun malestar o enfermedad 
frecuente nos reportan la siguiente sintomatologia: 

>- 26%) depresiones 

>* 23%) dolores de cabeza 

> 19%) gastritis 

>^ 15%) colitis 

>► 15% infecciones vaginales 

>■ 10%migranas 

>* 11% problemas dermatologicos 

Respecto a como se ejerce la violencia y la frecuencia 
de esta, en la mayoria de los casos es fisica con golpes 
de manos y pufios en diferentes partes del cuerpo y la 
cabeza con frecuencia que va de una semana a un mes. 

De las personas encuestadas solamente 8 mujeres 
refieren violencia durante el embarazo y solo tres son 
conscientes de que la violencia domestica le ha 
ocasionado problemas de depresion, dolores e 
incapacidad parcial. 

Como percibe la mujer la violencia implicita en sus 
relaciones de pareja a traves de los celos, el temor o la 
prohibicion, en las respuestas de mujeres maltratadas 



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tenemos un rango de 15 al 23% de respuestas 
afirmativas contra un 5 al 15% de respuestas 
afirmativas en mujeres que no reportan violencia. 
Con excepcion de algunas preguntas sobre 
prohibiciones o pedir permiso para salir que 
mantiene un porcentaje del 28 al 50% en mujeres no 
violentadas que reflejan que a pesar de no existir 
violencia fisica, si hay violencia psicologica. 

For ultimo, en cuanto a la violencia explieita en sus 
relaciones de pareja a traves del abuso sexual 
tenemos que el 21.6% reportan este hecho, y un 5% 
golpes en mujeres violentadas; en relacion con el 
3.7% de abuso sexual y 1.8% golpes en mujeres que 
no sufren violencia. 

CONCLUSIONES 

> Identificamos con una muestra de 106 encuestas 
la incidencia de la violencia domestica en 35% de 
la mujeres que acuden a los servicios de salud en 
ell.M.S.S. 

> Realizamos un primer acercamiento a la relacion 
violencia domestica-sintomas y enfermedades. 

> Existe relacion entre la violencia domestica y las 
enfermedades psicosomaticas que sufren las 
mujeres. 

^^ La mujer no percibe la violencia como un factor 
de relacion con su estado de salud-enfermedad, 
pocas son conscientes de ello. 

> No existen politicas institucionales de atencion a 
la salud y seguridad social integral de la mujer 
maltratada, solamente se detecta cuando la 
violencia es visible o presenta un cuadro 
depresivo-cronico, dando una atencion 
medicalizada-biologicista. 

> Es necesario relacionar el cuestionario aplicado 
con el expediente o historia clinica de la mujer 
maltratada a fin de hacer propuestas mas 
especificas para la atencion y deteccion respecto 
al binomio salud-violencia. 

>" Este primer acercamiento debe enriquecerse mas 
en el analisis del cruce de variables que nos 
permite realizar la muestra aplicada desde el punto 
de vista de la institucion y de otros organismos 
interesados. 

Propuestas 

En terminos generales la muestra nos arroja la 
relacion estrecha del binomio salud-violencia en la 
presencia de problemas psicosomaticos (que 
refieren las entrevistadas), trastomos que se 
presentan con caracteristicas de dolencias fisicas, 



pero que tienen su origen en el campo de la salud 
mental, al vivenciar los ciclos de violencia domestica 
en su estado de salud-enfermedad. 

En estos casos el tratamiento medico sera infructuoso, 
ya que el motivo de la consulta no tiene origen 
organico sino ocasionado por un alto nivel de 
tension (violencia) al que se ve constantemente 
sometida. De ahi la importancia de contar con 
altemativas para la prevencion y real atencion, a 
saber: 

> Continuar con el estudio de salud-violencia en las 
clinicas del I.M.S.S., Secretaria de Salud e 
I.S.S.S.T.E., a traves de una encuesta continua para: 

• Relacionar el costo de atencion a la salud de la 
victima de violencia (servicios de emergencia, 
aumento en la utilizacion de los servicios de 
salud primarios, de segimdo nivel y de 
especializacion) con el costo social. 

• Promo ver la atencion para la mujer maltratada 
desde un punto de vista integral no biologico. 

• Relacion de la violencia de genero con los 
indicadores de salud matemo infantil y 
programas de salud reproductiva. 

• Mejorar la calidad y calidez de la atencion a la 
mujer maltratada. 

♦ Elaborar un perfil descriptivo de la 

sintomatologia tipica de la mujer maltratada 
y del agresor para su canalizacion y mejor 
atencion a traves de: 
<> Programas de orientacion/prevencion. 
Programas de atencion medico- 

psicologica 
Programas de grupos o circulos de 
autoayuda. 
>- Promover la protocolizacion de investigaciones y 
cursos de capacitacion sobre la violencia de genero a 
todo el personal de los servicios de salud para 
sensibilizarlos de este problema social y por ende de 
salud publica. 
>- Incluir preguntas e indicadores sobre la violencia de 
genero en las historias clinicas y registros 
institucionales- 
>► Reconocer en la semantica o lexico medico el 
problema de la mujer agredida como grupo 
vulnerable del Sector Salud. 

> Proponemos un modulo de atencion para las/los 
derecho-habientes victimas de violencia como 
proyecto piloto de asistencia que puede ser 
manejado por el area de trabajo social o de medicina 
preventiva con personal previamente capacitado. 



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BARRIERS TO EMPOWERMENT 

IN HEALTH CARE 

CONSUMERISM 

Yvette Murray, Ph.D. 

Department of Social Work 

Southwest Texas State University, 

San Marcos, Texas 

ABSTRACT 

Traditional methods of service delivery often create 
barriers that impede clients from being participants 
in their own health care. Calling on my experience 
with treatment for breast cancer, this paper focuses 
on how self-determination can be compromised and 
illustrates the importance of empowering clients to 
be active partners in their own health care. It is 
essential for health care professionals to eliminate 
barriers to client self-determination and for social 
workers to educate their clients to be effective self- 
advocates. When clients are able to view 
themselves as consumers, they move out of the 
arena of passive recipients of health care and into 
active partnerships with health care providers, a 
move which can significantly affect the overall 
quality of services. 

Background 

Having been a health care provider for many years, 
I recently found myself in the role of a consumer 
seeking medical services for a life-threatening 
illness. Although I received excellent care from 
very sensitive, caring doctors and support staff, 
finding these professionals and certain aspects of 
the ensuing treatment involved some disconcerting 
experiences. This paper views problems in service 
delivery from my perspective as a patient and as a 
social worker. By relating my experience with 
treatment for breast cancer, I hope to heighten the 
awareness of medical service providers to barriers 
that impede patients from being active partners in 
their own health care. 

Discussion 

The traditional medical model of intervention 



encourages patients to be passive recipients of 
health care, leaving to chance the efficacy of the 
services they receive. The "best" patient is 
generally viewed as compliant, respectful of the 
doctor's time, and unquestioning of treatment. How 
are patients socialized into this passive role? This 
process begins when the patient contacts the doctor's 
office for an appointment. There were numerous 
instances where it was extremely difficult for me to 
schedule doctors' visits around my personal 
commitments because of a "take it or leave it" 
attitude about appointments by office staff. Daily 
responsibilities do not go away simply because one 
is having a health crisis. Indifference was better 
than outright rudeness, however. One doctor's 
office refused to schedule an appointment until it 
received notification from the insurance company, 
although my primary care physician had secured 
approval and faxed the information to them. 
Following a diagnosis of breast cancer, this refusal 
led to needless delay at a time of peak anxiety for 
me, when waiting several days for an appointment 
seemed like an eternity. Because we usually do not 
tolerate rudeness from other kinds of service- 
oriented professionals, why do we accept this 
treatment from health care personnel? We do so 
because we are frightened— our life is at stake! 

More insensitivity typically happens in the doctor's 
office, when the patient is confronted with intrusive 
intake forms that call for superfluous information. 
My favorite question asked if I wore seat belts, 
which seemed particularly ludicrous because at the 
time I was trying to get a second opinion about the 
need for chemotherapy. Other intake questions tend 
to be insensitive rather than funny. Why is it 
necessary to ask about race? What do people in 
committed relationships check when the only 
options are single, married, or divorced? Another 
common question requested an explanation if the 
respondent stated that birth control was not being 
used. During the times when I had enough energy 
to resist answering the irrelevant questions, the 
office staff invariably informed me that I had to fill 
in all of the blanks before I could see the doctor. 
Inflexibility progressed to condescension in one 
specialist's office, where I was told that the nurse 
would review the intake form to make sure that I 
had filled it out correctly. So much for treating 



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patients with respect. 

Because keeping doctors' appointments often 
involves considerable time in waiting rooms (rarely 
with the courtesy of an explanation), I have had 
ample opportunity to observe the interaction 
between support staff and patients. It is not an 
uncommon practice for the receptionists to call out 
questions, from their glass enclosures, to patients 
seated nearby. These questions concerned sensitive 
information about income, age, and reasons for the 
appointment. Such conversations were easily 
overheard by other office visitors. What happened 
to the ethics of confidentiality? Even more 
embarrassing were situations where patients were 
given instructions for laboratory tests and medical 
procedures in the reception area. One patient 
comes to mind who was going to have a lower 
gastrointestinal workup. The man turned scarlet 
when the nurse explained how to self-administer an 
enema with female patients seated only a few feet 
away. Does patient status mean that one has to 
forego any claim to personal dignity? 

In social work, we value the right of clients to self- 
determination; however, traditional methods of 
delivering medical services do not encourage 
clients to participate actively in their own health 
care. An all-too-frequent complaint is that the 
doctor was too busy to answer the patients' 
questions or explain the freatment. Even though I 
have no problem being assertive, it was often a 
struggle to get information because doctors seem to 
play the game of "ask me the right questions, and 
maybe I will give you some answers." Being 
diagnosed with breast cancer was sudden and 
fraumatic, leaving me ill-prepared to research 
pertinent questions. If physicians had been 
proactive in supplying information about laboratory 
tests and medical procedures, I would have felt less 
terrified and helpless. Furthermore, how can 
patients possibly make informed decisions about 
their health care without adequate information? 
The consequence is that others make decisions for 
us that affect our lives and emotional well-being. 

Consistent with paternalistic approaches to medical 
care is failure to adequately disclose the side effects 
of medication and treatment. To relieve nausea 
during chemotherapy, a drug was prescribed that I 



knew had psychotropic properties. When I 
questioned the doctor, I was told not to worry, that 
he was taking good care of me. A few weeks later, 
I began to experience blurred vision, dizziness, and 
insomnia. Checking the Physicians Desk Reference 
revealed that these symptoms were potential side 
effects of the medication. After confronting the 
doctor with this discovery, his response was, "Well, 
how many pills have you been taking?" In other 
words, the problem had to be my fault! In addition, 
I also discovered that this particular drug was habit- 
forming and very hazardous for driving. At the 
time, I was commuting 85 miles per day, oft:en in 
heavy traffic. The failure to disclose adequate 
information about this drug could have had lethal 
results; unknowingly, I was putting myself and 
others at risk. 

Another problem with health care services is 
indifference to patients' anxiety. The results of 
laboratory tests and x-rays are often available within 
24 hours; yet patients are forced to wait days for 
information. For breast cancer survivors, the delay 
in getting the results of a mammogram is 
excruciating. A negative report suggests that maybe 
the cancer is cured. Positive results mean more 
difficult freatment lies ahead in what is likely to be 
a losing battle with breast cancer. Contacting the 
doctor's office sometimes works in getting results. 
On other occasions, telephone calls are not retumed, 
or office personnel will not provide information. 
Are not kindness and understanding part of good 
medical practice? 

In the process of "curing" the patient, adherence to 
task often comes at the expense of human dignity. 
In my experience with chemotherapy, patients were 
lined up in rows of chairs less than 2 feet apart. 
These patients had to undergo freatments that lasted 
from one to several hours. During this time, their 
chief entertainment was the slow drip of infravenous 
tubes. Music, television, aquariums— anything 
would have been a welcome disfraction. The lack of 
privacy compounded the patients' misery. Because 
they were seated in proximity, patients heard the 
intimate details of everyone else's medical situation. 
Female patients who were receiving chemotherapy 
through chest catheters sat with their blouses open 
within view of male patients and visitors. When 



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one elderly lady attempted to maintain some 
measure of modesty, she was curtly reminded that 
the staff was trying to save her life. People who 
have experienced cancer do not need to be 
reminded of their mortality! 

In this overview of my experience as a cancer 
patient, I have described barriers to consumer 
participation at various levels in the medical 
system. If, as an articulate, assertive social worker, 
I had considerable difficulty in maintaining an 
informed, participatory role in my own health care, 
what is the likelihood that others will succeed who 
do not have the benefit of my education and 
training? What can we do as social workers and 
service providers about medical delivery systems 
that are antithetical to personal dignity and self- 
determination? To be effective, intervention 
strategies such as the following must target both 
providers and patients: 

>^ Train support staff about empathic 

communication and confidentiality. 
>" Affirm the right of clients to be treated with 

kindness and respect by support staff as well as 

service providers. 
> Eliminate needlessly intrusive intake procedures. 
^^ Respond to patients' anxiety with timely 

disclosure of medical results. 



>► Provide patients with adequate information to 

facilitate informed decision making. 
^^ Create a climate where patients feel free to ask 

questions. 
>" Implement consumer satisfaction surveys as an 

integral part of the service delivery process. 
>* Promote health care consumerism by educating 

patients to be effective self-advocates. 
>" Refer patients to self-help and advocacy groups. 
In retrospect, the majority of the problems I have 
encountered with medical services do not require 
expensive solutions, only sensitivity and 
thoughtfiilness. It is all too easy for busy health 
care personnel to focus on the diagnosis and related 
tasks rather than on the psychosocial needs of the 
frightened human being who is under their care. For 
patients to have the best possible chance of 
recovery, they must be empowered with adequate 
information and encouraged to be part of the 
decision making and treatment process. When 
barriers to empowerment are eliminated, patients 
regain some measure of control over the health 
crisis that has upset their emotional equilibrium. 
And, by acting as consumers, patients move out of 
the arena of passive recipients of health care and 
into an active partnership that can significantly 
affect their survival and quality of life. 



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PRIMARY HEALTH CARE 

SERVICES FOR WEBB COUNTIT 

COLOMIAS 

Gloria Pena, R.N. 

City of Laredo IHealtli Department 

Laredo, Texas 

Rose A. Saidivar, M.S.N. , R.N. 

Primary l-lealtli Care Services for 

Webb County Colonias 

Lisa Sanford, M.P.H., R.N. 

Rosemary Welsh, R.S.M., R.N. 

Mercy Regional Medical Center 

Laredo, Texas 

Donna Morris, Dr.P.H., C.N.M. 

University of Texas Medical Branch 

Galveston, Texas 

ABSTRACT 

Primary Health Care Services for Webb County 
Colonias is financially supported by the D.D. 
Hachar Charitable Trust Fund and the Robert Wood 
Johnson Foundation. This project integrates 
services of a local health department, a private not- 
for-profit health center, a private not-for-profit 
hospital, and the county government to improve the 
availability and accessibility of resources to an 
indigent, rural population. The project uses a 
central staff and rotating health care teams led by 
nurse practitioners. Its goal is to establish a long- 
term, sustainable primary health care program for 
individuals who live in the colonias of Highway 
359. Based in a mobile van, the project uses 
community outreach and health education concepts 
to provide basic health care and chronic disease 
screening for women and children. This project 
fosters the professional development of local 
nurses' expertise in women's health issues. This 
program will be expanded to serve a wider 
population and also serve as a model for other 
communities along the U.S.-Mexico border that are 
experiencing difficulties in connecting existing 
health resources with those who need them most. 



Discussion 

According to the 1990 census, Webb County has a 
population of 131,623, of which 91% are of 
Hispanic origin. Laredo is one of the oldest cities in 
Texas and is one of the fastest-growing cities in the 
country, second only to Las Vegas. Laredo has one 
of the youngest populations in the country, with an 
average age of 23 to 27 (Rust, 1993). Of cities with 
a population of 100,000 or more, Laredo has the 
highest poverty rate in the nation. More than 37% 
of the population lives in poverty, and the minimum 
income is $19,527. In the colonias, the average age 
is only 18.5 years, compared with 30.8 years 
statewide. Fifty-four percent of the population is 
between 14 and 55; 52% percent is female, 
indicating a large population of women of 
childbearing age. The average poverty rate for 
border counties in 1989 was about 35%, compared 
with 18%) statewide. Seven of the 10 poorest 
counties in Texas are on the border, Webb County 
being one of them (Texas Department of Health, 
1993). 

In a 1990 study by the Texas Cancer Council, the 
risk of death fi-om cervical cancer in Webb County 
was found to be two and one-half times greater than 
the statewide average among women of Hispanic 
origin who live along the Texas-Mexico border. In 
this same study, Hispanic women living in 
Cameron, Hidalgo, Willacy, and Webb counties 
have three times the risk of death fi"om cervical 
cancer. 

Laredo, Webb's county seat, has been identified by 
the Children's Defense Fund as having the second 
highest poverty rate for children in the United 
States. Almost 50%, or 22,500, of Laredo's children 
live in deplorable conditions. 

At least 10,000 people live in the colonias 
surrounding Laredo. This is a conservative estimate 
at best because not everyone was actually counted 
in the 1990 census. The South Texas Development 
Council defines a colonia as "an unincorporated 
area populated as a primarily residential 
development with substantial substandard housing 
and/or without the benefit of adequate water supply 
and/or wastewater services." There are 

approximately 40 to 60 colonias in Webb County. 
The problems of not having any water and 



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sewage cannot be fully understood until one has 
lived in these conditions and/or has attempted to see 
from the perspective of those living in the colonias. 
The closest water source for most residents is 
approximately 10 miles from their home. For those 
residents who have no car, 10 miles seem like 100 
miles. 

In most of the colonias, there is no frash pickup, 
even though a State law mandates this. 
Transportation is minimal or nonexistent. Disease 
is rampant: cholera is a real threat, as is dengue 
fever. Recently, a documented case of dengue fever 
was found in McAUen, according to the September 
21, 1995, issue of the San Antonio Express . 
Concerns are that mosquitoes will spread this 
disease in the colonias due to stagnant water 
sources and substandard housing conditions such as 
the lack of screened windows. Cholera has been 
found in the sampling of water from the Laredo 
sewage system, but no documented cases have 
surfaced thus far. 

A 5 -year sustained outbreak of rabies among 
coyotes in South Texas has claimed at least one 
human life. People who live in the colonias have a 
greater risk from rabid dogs infected by wild 
coyotes, simply because of their proximity to the 
problem. Efforts are in progress to bring the rabies 
vaccine to pet owners in the colonias. 

Infectious diseases such as tuberculosis (TB) are on 
the increase. There are indications of increased 
levels of antibiotic-resistant strains of TB, syphilis, 
and gastrointestinal diseases. Chronic diseases 
account for almost 65% of deaths along the border 
(Pan American Health Organization, 1993). 
Leading among these diseases are diabetes, 
cardiovascular disease, and cancer. 

There are increased rates of Hepatitis A and 
Hepatitis Unspecified (which may include an 
environmentally fransmitted Non-A and Non-B): 
this is of note because Type A and possibly Non-A 
and Non-B are water and sewage fransmissible 
(Morris, 1993). Dr. Maurice Click, Medical 
Director for the Gateway Community Health Center 
in Laredo, states that the uniqueness about working 
in medicine here is that it is four worlds of disease 
in one — the ancient diseases such as leprosy, TB, 



and rabies; the modem-world diseases including 
gunshot wounds, HIV, and auto accidents; the Third 
World diseases of dysentery, lead poisoning, 
cholera, and plague; and the new world syndromes 
of diabetes, obesity, and hypertension. More than 
half the patients who see Dr. Click and other 
physicians on the border suffer from diabetes and 
hypertension. Most deaths result from these "new 
world" diseases (Texas Department of Health, 
1993). 

Before 1992 there were few, if any, health services 
available in the colonias. More than 36% of 
border residents have no health insurance and are 
not covered by medicaid or medicare. Hispanics are 
more likely than any other ethnic group in the nation 
to have no health insurance, and they comprise 46% 
of Texans who are uninsured. This is only partly 
due to unemployment rates. Forty-five percent of 
Hispanic families with employed members still lack 
health insurance (Texas Department of Health, 
1993). People with insurance lack a primary health 
care provider due to the shortage of health care 
providers in the Laredo area (Mercy Regional 
Medical Center, personal experience). Access to 
health care and transportation are barriers to 
successfully entering the health care system. Many 
times people prefer to go to Nuevo Laredo, our 
sister city in Mexico, to seek medical intervention 
and medications because it is less expensive and 
always easier to access. 

After hearing the above, one might ask why families 
would choose to live in the colonias. The housing 
shortage in Laredo has become a very significant 
problem. Housing is very expensive and scarce. 
Public housing is difficult to get into and there may 
be as many as 2,000 families waiting for it (Morris, 
1993). An apartment in Laredo could cost as much 
as two to two and one-half times more money than 
one in San Antonio or Houston. A one-room 
apartment in Laredo costs about $250 a month. 

Contrary to public opinion, not all who live in the 
colonias are undocumented people. Many are first-, 
second-, and third-generation Mexican Americans 
who want their own piece of land to call home. 
They are willing to tolerate the many hardships so 
their children can have a place to live. Still others 
may simply have no other option. 



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Early Efforts to Meet the Needs of the 

colonias 

In light of all the above, our project, the Primary 

Health Care Services for Webb County Colonias, 

seemed appropriate to address the needs of the 

community, although it was not the first attempt to 

respond to the needs of the people in the colonias. 

In the spring and summer of 1992, people from 
various health agencies in Laredo began making 
initial visits to the homes of the residents living in 
the colonias along Highway 359. Contacts were 
also made with the local churches, stores, and the 
schools the children attend. Colonias along 
Highway 359 were selected because they were 
densely populated, had inadequate transportation, 
and lacked the basic infrastructures. There are 
approximately 11 to 15 colonias along Highway 
359. 

After talking with many people, visiting many 
homes, and listening to a lot of ideas, we decided to 
respond on a small scale to some of the needs of the 
people. We knew that the children needed to be 
immunized so we began to have Convivios Pro- 
Salud: (Pro-Health Get Togethers). In the colonias, 
we would offer immunization for children and also 
for adults. We would also screen people for 
diabetes and hypertension. We had educational 
programs and gave out literature and information on 
existing agencies and programs such as the Special 
Supplemental Nutrition Program for Women, 
Infants, and Children (WIC) and Early Childhood 
Intervention (ECl). We always had these fiinctions 
around a culturally significant event such as the 
feast of Our Lady of Guadalupe, Las Posada at 
Christmas, and Easter. We had piiiatas, games, 
prizes, and goodie bags for those who attended. 
The goodie bags consisted of anything from school 
supplies, toiletries, cleaning supplies, and toys for 
the children. We asked for assistance from the 
Laredo Rotary Clubs, local stores, churches, and 
individuals. We gathered demographics and asked 
for ideas for friture activities. The projects have 
grown and now have more than 10 agencies 
participating. 

These events were significant because they gave us 
the opportunity to be with the people in their 
environment, to earn and gain their confidence, and 



to hear their perspective on how we might continue 
to journey with them. As time has gone by, the 
people have become active participants in the 
planning, preparation, and execution of these events. 

All of this information is important to understand 
why, when the opportunity presented itself, we 
chose to continue our journey, walking with and 
offering services to the people in the colonias, by 
joining in this project. 

The Beginning of the Project 

In the spring of 1993, a group of individuals 
representing various health, education, business, 
county, and religious institutions came together to 
investigate the possibility of obtaining a grant from 
the Robert Wood Johnson Foundation and the D.D. 
Hachar Charitable Trust Fund of Laredo. This grant 
would begin to address some of the identified health 
needs of the colonia residents through education and 
prevention components. This group was 
spearheaded by a local physician. Dr. Joaquin 
Cigarroa, a board member of the D.D. Hachar 
Foundation and the adminisfrator of this charitable 
trust. Because of a history of collaboration with the 
University of Texas Medical Branch at Galveston 
(UTMB), Dr. Donna Morris was invited to Laredo 
to act as Project Director. The initial group grew 
into a steering committee and then an advisory 
board with representatives from three of the 
colonias in the targeted area. 

From the very beginning, the people of the colonias 
have been the heart and soul of the project. Our 
main goal is to establish a long-term, sustainable 
primary health care program for individuals who 
live in the colonias of Highway 359. In 
accomplishing this, the availability of resources to 
an indigent, rural population and the colonia 
residents will improve, and residents will have been 
integral during the planning and implementation. 
There were many meetings between residents and 
providers. When we started, more than 320 projects 
were seeking these funds. Through the grant review 
process, the number was reduced to 64, of which 
only 20 received site visits, and Laredo was one. 
Again, it was important that the people of the 
colonias were involved, listened to, and had the 
opportunity to share their ideas, support, and hopes 
for this project. It was crucial to the agencies 



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involved to show that the people wanted this project 
and accepted responsibility to help make it a 
success. Representatives from the Robert Wood 
Johnson Foundation were taken to the colonias and 
over 100 residents were present to speak with the 
representatives. We believe it was their 
involvement and support in this event that fostered 
the approval of our grant. 

In the spring of 1994, after more than a year of 
meetings, preparations, and discussions, we were 
awarded the grant. The Project Steering 
Committee, composed of representatives from the 
ftmding agencies— the City of Laredo Health 
Department and two not-for-profit health care 
facilities, Gateway Community Health Center and 
Mercy Regional Medical Center— began to plan the 
implementation of the project. We needed to: 

>- Identify the nurses who would attend the Women 
Nurse Practitioner program. 

> Develop tutoring classes for these niu-ses, thus 
ensuring their success in the practitioner program. 
(Our project was fortunate to have several good 
candidates and a Clinical Nurse Specialist in 
women's health to offer tutorial courses in 
women's health issues.) 

>► Get input from the colonia residents. 

>- Establish partnerships with the State of Texas 
Attorney General's Office, the residency program 
of the University of Texas Health Science Center 
in San Antonio, the Lyndon B. Johnson School of 
Public Affairs, Texas A&M University, and a 
CBS interview with Ed Bradley from "60 
Minutes." 

During our numerous inquiries regarding mobile 
vans, we were fortunate to inspect a van en route to 
Mexico from Lifeline Shelter Systems in 
Columbus, Ohio. From this viewing in Laredo, we 
were able to conserve time and money and avoid 
out-of-town travel. From this model, we were able 
to develop a design to meet our needs. 

We also developed and wrote job descriptions for 

the following staff positions: 

>> Driver of van/j anitor 

s* Consejeras (lay health promoters) 

>" Health office assistants 

>* Field coordinator (social worker) 

>► Administrative assistant 

> Nurse coordinator 



It was very important to match the jobs with the 
right people. We wanted people who could frilly 
join with our philosophy of listening to and 
journeying with the people. We needed individuals 
who were bilingual and also sensitive to the culture 
of the people in the colonias. We needed people 
who would not see this as just a job. Thankfiilly, we 
found them. 

Even though the van is air-conditioned, we are 
outside a lot, and it is hot. The van is equipped with 
water tanks, which make hand-washing and 
restroom facilities in the van workable. A portable 
toilet is available at the van site and bottled water is 
purchased for drinking. Playground equipment was 
donated for the children who come for or with their 
parents. 

I cannot stress enough the positive aspects of the 
collaboration from the participating agencies. We 
had committees with representatives from the 
different funding agencies to determine how we 
would come up with needed forms such as consent, 
encounter, and registration. We had a committee to 
look at the financial, billing, and computer 
systems of the different institutions. Other 
committees developed joint nursing protocols for 
women's services, children's immunizations, and 
screening for diabetes and hypertension. 
Collaboration with other agencies has been very 
important from the beginning of this project. 
Though it has been a very positive aspect and a key 
to getting the grant, it has also been one of the most 
challenging, and not without its difficulties. 

Conclusion 

Some ideas or aspects that made the project 

successful include the following: 

>► The early establishment of an Advisory Board 

with colonia residents as members 
> Gateway Community Health Center's experience 

with migrant and seasonal farmworkers 
>► Mercy Regional Medical Center's health care 

experience, history in Laredo, and hirnian 

resources 
>► Laredo Health Department's public health 

knowledge and WIC services 
>* Job interviews and hiring the right people 
>► Consejeras selected from the residents who hve in 

the colonias 



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Field Coordinator's previous experience with the 
development of a similar program in Matamoros. 

>■ Time spent with the people in the colonias prior 

to the awarding of the grant 
> Health fair activities such as Convivios and 

Kermes 

We have our struggles and problems and still have 
much to leam. For example, even though the 
mobile van is available in the colonias, there is no 
public transportation between the colonias. People 
still have long distances to walk to obtain our 
services. The lack of public transportation in the 
colonias is a great obstacle. Our program, in 
collaboration with Texas A&M School of 
Engineering, the Community Action Agency, and 
Mercy Regional Medical Center, is working toward 
improving transportation. 



Primary care and prevention services are much 
needed in the colonias of Highway 359. Our 
program has provided multiple health and other 
related services directly to the residents of the 
colonias. We do not expect the people to express 
appreciation for what we do because they deserve 
these services and a better quality of life. 

One has to know and understand the people to 
advocate for their needs, but first of all the people 
have to allow one to advocate for them. This 
project is striving to improve systemic change in 
the health care community of Laredo. Multiple 
liaisons are necessary as resources to accomplish the 
end result of healthier residents of the colonias of 
Highway 359. 



REFERENCES 



Morris D, Hannigan E, Dayal H, Moore F, Selwyn B, 
Loe H, McCandless R, Rosenthal J. Final Report. 
South Texas Needs Assessment . Austin, TX: Texas 
Cancer Council, 1993. 

Pan American Health Organization. Planting the 
seeds: Binational efforts to improve maternal and child 
healthcare in the United States - Mexico border 
area. 



Washington, DC: PAHO, Camegie Corporation of New 
York, The Pew Charitable Trusts, 1993. 

Rust C. Dreams and dust. Texas: Houston Chronicle 
Magazine . July 25, 1993. 

Texas Department of Health. 1993-94 Annual Report . 
Austin, TX, 1993. 



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A TELECOMMUNICATION 

STRATEGY TO BUILD NEW 

MEXICO'S RURAL PRIMARY 

CARE NETWORK 

Jo Fairbanks, Ph.D. 

University of New Mexico 

Area Health Education 

Diane Viens, D.N.Sc, C.F.N.P. 

Family Nurse Practitioner Program 

University of New Mexico 

College of Nursing 

ABSTRACT 

New Mexico has a severe shortage of primary care 
providers practicing outside its few urban areas. 
Health professionals who do live and practice in 
rural areas have a very limited opportunity to 
further their education. In New Mexico, for 
example, many rural nurses are interested in 
advanced degrees. But to pursue advanced nursing 
degrees, they would have to leave their 
communities to attend a university many miles 
away. 

A collaborative distance-education project 
involving the University of New Mexico College of 
Nursing, the Area Health Education Center, and 
Western New Mexico University has provided a 
partial solution to this problem. Six registered 
nurses living and practicing in a rural site are now 
receiving their Family Nurse Practitioner degrees 
via two-way audio/video teleconferencing 
equipment. These nurses are able to continue living 
in their communities while they attend block 
classes especially designed for distance education 
and transmitted by the University of New Mexico 
College of Nursing. The first New Mexico 
classroom site is at Western New Mexico 
University in Silver City. Five more sites will be 
developed throughout the State. The outcome will 
be that nurses currently working in rural sites can 
become nurse practitioners, thus improving the 



capacity to provide primary care in rural 
communities. 

Issues 

Technology 

The New Mexico project chose to transmit using 
teleconferencing equipment that basically requires 
a camera, a monitor, and a codec at each site. The 
codec compresses the analog video signals into 
digital, which can then be transmitted over 
telephone communication sy^stems. Adequate 
resolution for classroom teaching can be achieved 
with 112 KB of bandwidth. The major advantage of 
this system is two-way interactive audio and video 
allowing for dialog and communication among 
several sites. This system is usually less costly than 
satellite delivery. A disadvantage is that there is an 
approximately 2-second transmission delay on 112 
KB bandwidth. This delay can be eliminated by 
dialing up more bandwidth; as bandwidth increases, 
delay is reduced and resolution improves. 

Cost 

A priority for any new program is to assess the 
costs. The cost of lines, installation, and monthly 
charges for teleconferencing transmission can be in 
excess of the original cost of the equipment. If the 
method of choice is teleconferencing equipment 
delivery, phone lines must exist to carry at least 112 
KB bandwidth to the off-campus site. As 
bandwidth is increased to reduce the delay 
experienced in the image on the monitor, costs 
increase proportionately. 

Site Preparation 

A fixed classroom site is preferable because moving 
the equipment can cause transmission problems and 
the unit needs to be connected to special phone 
lines. If the remote site classroom is in another 
institution, issues of technical support, room costs, 
monthly charges, equipment preparation, and 
troubleshooting equipment problems must be 
addressed. 

Adequate Preparation for Faculty and Students 

Faculty input into the proposed distance-education 
project must be encouraged. Faculty must be given 
ample time to observe the use of the equipment and 
have direct hands-on experience with the unit to 
adjust their teaching style and revamp their teaching 
equipment. Students, both at the transmission and 



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receive sites, must be prepared for what to expect 
and they need to practice on the equipment. 
Student seating must be arranged at each site so that 
students will be able to see each other. Students at 
both sites should be brought together face-to-face 
on a regular basis. Each faculty member should 
teach a few classes from the remote site. 

Support Services for Students at the Distant 

Site 
Library— On campus. Plans must be made with the 
full-service university library staff to provide basic 
library support for off-campus students. This 
support can take a variety of forms but will 
certainly involve access to online searches and 
hard-bound volumes, interlibrary loans, copying, 
faxing, and mailing requested articles. It may be 
necessary to plan and budget for additional staff to 
meet the distant students' library resource needs. 

Library— Off campus. The collection of the library 
at the remote site must be assessed for the 
appropriateness of hardback volumes and journal 
subscriptions suitable for the students. 



Preceptorship Sites 

There must be adequate clinical preceptorship sites 
available to meet the needs of all students for the 
entire length of the program. The program should 
plan to have at least two to three qualified, willing 
preceptors and two to three clinical sites per student 
in each remote area. 

Conclusion 

New Mexico's project has demonstrated that 
distance education via two-way audio/video 
teleconferencing equipment can be an effective 
method of educating nurse practitioners. Distance 
education can build primary care capacity in 
underserved areas. However, distance education 
requires considerable preparation and appropriate 
allocation of resources to ensure that remote site 
students' educational needs are not compromised. 



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PRESCHOOL IMMUNIZATIONS 

IN HISPANIC TEXANS: THE 

EFFECT OF 

SOCIODEMOGRAPHICS, 

KNOWLEDGE, AND ATTITUDES 

OF HISPANIC MOTHERS 

Diane M. Simpson, Ph.D., M.D. 

Lucina Suarez, M.S. 
Texas Department of Health 

ABSTRACT 

A household survey of the immunization status of 
over 4,800 Texas children 3-24 months of age was 
conducted during the summer of 1994 to compare 
rates of Hispanic Texas children to those for non- 
Hispanic Texas children and to determine which 
maternal factors help predict up-to-date 
immunization status. Immunization status was 
determined through immunization records (72%) or 
parental recall. Questions on sociodemographics 
(race/ethnicity, use of public assistance programs, 
and insurance) and the respondents' knowledge and 
attitude about preschool immunizations were also 
asked. 

Overall, Hispanic children had the highest rate 
(58.6%) of up-to-date immunization status when 
compared with Anglo (56.9%) and African- 
American (39.3%) preschoolers. When compared 
with Anglos and African Americans, Hispanic 
children were also more likely to be uninsured 
(44%)), participate in the Special Supplemental 
Nutrition Program for Women, Infants, and 
Children (WIC) (67%)), and use public vaccine 
clinics (71%). African- American and Hispanic 
mothers were more influenced by the opinions of 
their relatives, friends, and ministers than were 
Anglos. They were also more concerned about the 
safety and efficacy of vaccines. 

Despite recognized barriers, Hispanic mothers are 
more apt to have their children immunized 
according to recommended schedules. This was 



particularly evident along the border in El Paso and 
Hidalgo Counties. Various factors such as 
participation in WIC and family values may explain 
these results. 



Texas Immunization Survey 

Survey Methods 

>* Household in-person interviews 

• 10 counties targeted for 400 interviews 

• 20 counties selected at random 

>* 11 6,000 households screened for children 3-24 

months 
>> 4,832 completed interviews 

• Response rate: 85% 

• Hispanics in survey: 49% 

>" 72% of respondents had immunization records 



Counties Sampled 




Smaller sampled counties (sample size 
less than or equal to 50) 

Larger sampled counties (sample size 
between 51 and 150 

Targeted counties (400 interviews) 



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1 



Immunization Rates 3-24 Months 
By County 



Percent UTD 
100 

90 



70 
60 




n Anglo ■ Hispanic ■ African-American 



Texas Immunization Survey 

Up-to-date Immunizations by Socioeconomic Status 



Texas Immunization Survey 

Up-to-date Immunizations hy Ethnicit 





100 
80 




0) 


60 




-57%- 


_ 59% _ 




o 


40 




55% 




■ 









_ 39%_ _ 






20 

n 


. 






1 


1 





State Anglo Hisp. Afri. 




<100% >100% 

Federal Poverty 




Not employed Employed 
Employment 




<HS HS Some College Grad 
College 

Education 



Page 266 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



Texas Immunization Survey 

Up-to-date Immunizations by Age of Child 





lUU 

80 
An 


82% 












65% 




Q 

1- 
3 








58% 








S5 


40 
20 






^^^1 




38% 










1 










3^ 


5-6 7-15 


16-24 












Age(l\/ 


lonths) 







Texas Immunization Survey 

Up-to-date Immunizations by Mother's Demographics 



10Q- 



100 



Q 60 




5^ 40 



Married Divorced/ Never Married 
Separated 

Marital Status 







<20 20-30 >30 
Mother's Age 



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U.S. - MEXICO J 995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 






Texas Immunization Survey 

Up-to-date Immunizations by Insurance 



100 



o 

H 
Z3 




None Medicaid Private 



Texas Immunization Survey 

Up-to-date Immiuiizations by Source of Care 




Public Private 



Parent's Characteristics 



Q 

H 
Z3 




Public 
Parent's Characteristics 



o 

3 




H Anglo 

■ Hispanic 

■ Afr. American 

■ H.S. Grad 
n<100%Pov. 
D Employed 

■ Never IVIarried 

■ Married 

D Imm. Record 



B Anglo 

■ hllspanic 

■ Afr. American 

■ H.S. Grad 
n<100%Pov. 
n Employed 

■ Never Married 

■ Married 

D Imm. Record 



Private 



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U.S. - MEXICO J995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



Texas Immunization Survey 

Up-to-date Immunizations by Public Assistance 



100 




Food Stamps 

Yes/No 



AFDC 

Yes/No 



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i 



U,S, - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



PREVENTION OF CERVICAL 

CANCER AMONG 

U^. LATINAS 

Maria Eugenia Fernandez-Esquer, Ph.D. 

Center for Health Promotion 

Research and Development 

UT-Houston School of Public Health 

Amelie G. Ramirez, Dr. P.H. 

Roberto Villarreal, M.D. 

South Texas Health Research Center 

University of Texas 

Health Science Center 

San Antonio, Texas 

ABSTRACT 

Latinos have the world's highest reported incidence 
of cervical cancer. They also have a low 
compliance rate with cancer screening guidelines 
compared to other ethnic groups. Sexual behaviors, 
including the number of sexual partners and the age 
of onset of sex are considered important risk 
factors, especially among women having 
unprotected sex with multiple partners. 

This paper presents results obtained in a national 
telephone survey that was conducted among Latinos 
of different nationalities to measure risk behaviors 
and screening practices associated with different 
forms of cancer. Specifically, the paper discusses 
the association between behaviors that place 
Latinas at risk for cervical cancer and certain 
cultural characteristics. Significant findings 
indicate that cancer prevention campaigns should 
tailor interventions to their specific cultural 
characteristics and needs. 

Objectives 

> To present survey results that point to differences in 
risk behaviors associated with cervical cancer 



reported by Latinos of different nationality 
backgrounds 

>* To highlight the importance of sexual behavior as a 
risk for cervical cancer 

Rationale 

>■ The risk for cervical cancer is higher among women 
who smoke, start having intercourse at an early age, 
have unprotected sexual intercourse with multiple 
partners, or with a partner who has multiple partners 
(Yoder and Rubin, 1992; Zunzunegui, et al., 1986). 

^^ Latinas have the highest reported incidence of 
cervical cancer in the world (Reeves, et al., 1984). 

>- Latinas tend not to comply with cervical cancer 
screening guidelines (Harlan, et al., 1991). 

Procedures 

>■ A national telephone survey was conducted for the 
En /4ccwn/National Hispanic Leadership Initiative 
in Cancer to pretest measures for community 
interventions presently under way in six different 
cities across the United States. 

>■ Bilingual/bicultural interviewers randomly selected 
one respondent per household according to 
prespecified age/gender criteria. The interview 
lasted 15-20 minutes and was conducted in the 
respondent's language of preference. 

Participants 

>■ A total of 8,903 self-identified Latinos completed 
the survey. Fifty-three percent of the sample 
(4,733) were women evenly divided into two groups 
of under/over 40 years of age. 

Instrument 

>■ The telephone survey included questionnaire items 
measuring screening practices and risk behaviors 
associated with breast, cervical, colorectal, prostate, 
and skin cancer. 

Data Analysis 

>- The association between sociodemographic (age, 
income. Latino group, acculturation) data to cancer 
risk behavior variables (Pap smear screening and 
sexual activity) was estimated using the chi-square 
statistic. 

>- The following results are indicated in percentages. 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



i 



J 



Cervical Cancer Risk Behaviors 
By lATiNA Group 

















"J J. 




Condoms — 


Onset sex 


Ever had Pap 




XT' ssx 






partners 


main partner 


other partners 


(<16yrs) 


smear 


Mexican 
Americans 


2.5 


10.8 


30.9 


45.1 


77.8 


Central 
Americans 


2.1 


13.2 


55.6 


43.7 


79.4 


Puerto Ricans 


3.6 


19.9 


58.8 


60.4 


82.1 


Cubans 


1.7 


12.6 


25.0 


33.3 


79.0 


Other Latinas 


4.4 


14.1 


25.0 


43.8 


84.9 



Cervical Cancer Risk Behaviors 
By Age Group 

Percent 




.^ 



^fe^ 






.^^ .^r.^^^^.^*• ^^^ 



9'^ .^*\6>®' 



^^^- >- d^^V'^^o.*^'^ 



*<? 






^" .d^ ,K<^ 



0° O' 



By Income Level 



By Acculturation 

(Lang ua ge Use) 













Mostly 




Mostly 




Spanish 


Bilingual 


English 


Multiple 
partners 


1.5 


3.5 


6.4 


Condoms — 
main partners 


9.4 


16.8 


18.1 


Condoms — 
other partners 


26.9 


48.6 


32.7 


Onset sex 
(<16) 


44.7 


42.9 


50.3 


Ever had Pap 
smear 


77.6 


78.4 


85.3 



By Ljevel OF Education 




.<^ 



/^ 








<HS 


HS Grad 


:::.:.:::.:.:.:.:.:^^;.::.:-:--.:;: 


Multiple partners 


1.7 


4.1 


2.8 


Condoms —main 
partner 


9.9 


33.3 


41.5 


Condoms —other 
partners 


29.1 


33.3 


41.5 


Onset sex (<16) 


50.9 


42.3 


33.0 


Ever had Pap 
smear 


76.1 


81.9 


83.6 



Page 272 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



1 



By Marital Status 



Percent 




■ Married 

DNot 
Married 



»<* ^^ ^ A^ «.** 



^^'\^^^ 






,^ 



^"^>^:;^^ °' .^^* 



OO" 



Results^ 



«.ev°^ 



Multiple sexual partners 

• Women who reported having sex with two or 
more partners in the last year were more likely 
to be Puerto Rican or from Latino groups (such 
as Caribbean, South American), under 40 years 
of age, earning over $20,000 a year, highly 
acculturated, high school graduates, and not 
married. 

Condom use with main partners 

• Women who reported always using condoms 
with their main sexual partner were more likely 
to be Puerto Rican, imder 40 years of age, 
highly acculturated, with some college 
education, and not married. 



> Condom use with other partners 

• Only one sociodemographic factor was 
significantly associated with condom use with 
other (casual) partners: women who were not 
currently married were more likely to report 
always using condoms with their other partners. 

>* Onset of sexual activity 

• Women who initiated sexual activity before they 
were 16 years of age were more likely to be 
Puerto Rican, under 40 years of age, earning an 
annual income under $20,000, highly 
acculturated, but with no high school degree. 

> Lifetime Pap smear use 

• Women who reported ever having a Pap smear 
were those who reported earning over $20,000 a 
year, being highly acculturated, with a high 
school degree or higher level of education, and 
married. 

Conclusion 

>■ Cancer prevention campaigns should not only 
emphasize the common cultural roots that exist 
among Latinos of different nationality backgrounds, 
but should also tailor specific interventions according 
to their sociodemographic characteristics. There is a 
strong need to promote condom use to prevent 
cervical cancer, among all women who have a main 
partner, and particularly among those who also have 
additional partners. 



' These results are based on only significant associations 
between the sociodemographic predictors and risk behaviors. 



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U.S. - MEXICO 1995 BORDER CONFERENCE ON WOMEN'S HEALTH 



i 



BtBUOGRAPHY 

Harlan, LC, Bernstein, AB, Kessler, LG. Cervical Yoder, L, Rubin, M. The epidemiology of cervical 

cancer screening: Who is not screened and why? cancer and its precursors. Oncology Nursing Forum. 

American Journal of Public Health. 1991;81:7(885- 1992;19:3(485-493). 

Zunzunegui, M, King, M, Coria, C, Charlet, J. Male 
Reeves, W, de Britton, R, et al. Cervical cancer in influences on cervical cancer risk. American Journal 

the Republic of Panama. American Journal of of Epidemiolog y. 1986; 123.(302-307). 

Epidemiolog y. 1984; 119(714-724). 



Page 274 Posers 



The University of Texas System-Texas-IVIexIco Border Health Coordination Office»Area Health Education Center 
of South Texas'The Centers for Disease Control and Prevention-National Cancer lnstitute»National Institute of 
Allergy and Infectious Diseases-National Institute of Arthritis, Musculoskeletal and Skin Diseases-National Insti- 
tute on Child Health and Human Development-National Institute on Diabetes and Digestive and Kidney 
Diseases-National Institute on General Medical Sciences-Office of Research on Women's Health-Office on 
Women's Health-Arizona-Mexico Border Health Foundation-/Wt;yeres Project of San Antonio and the Rio Grande 
Valley-Planned Parenthood Association of Hidalgo County-Planned Parenthood Federation of America-The Texas 
Association of Obstetrics and Gynecology-The United States-Mexico Border Health Association-University of 
Texas-Pan American-University of Texas Health Science Center at San Antonio-South Texas AIDS 
Training-University of Texas, Houston Science Center-School of Nursing-The UpJohn Company